instructions to applicants for licensure - d&d nclex reviewddnclexreview.com/_images/4-bvnpt...
TRANSCRIPT
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
INSTRUCTIONS TO APPLICANTS FOR LICENSURE AS A LICENSED VOCATIONAL NURSE
Notice to Individuals (Civ Code Sec 179817) -- ALL items of information requested in this application are mandatory Failure to provide any of the requested information will result in the application being rejected as incomplete The information requested will be used to determine qualifications for examination andor registration under the Vocational Nursing Practice Act The official responsible for information maintenance is the Executive Officer at the above noted address and telephone number The information may be transferred to another governmental agency such as a law enforcement agency if necessary for the agency to perform its duties Individuals have the right to review the files or records maintained on them by our agency unless the records are identified as confidential information and exempted by Section 179840 of the Civil Code
PLEASE FOLLOW THESE INSTRUCTIONS CAREFULLY WHEN COMPLETING YOUR APPLICATION
STEP 1
APPLICATION FOR VOCATIONAL NURSE EXAMINATION AND LICENSUREndashTo apply for the Vocational Nurse examination and licensure you must submit the following
A Application for Vocational Nurse Licensure (55A-1) ndash Complete and sign the Application for Vocational Nurse Licensure
B Social Security Number ndash Business and Professions Code Section 30 and Public Law 94-455 [(42 USCA(c) (2) (C))] authorize collection of your Social Security Number Applications for licensure will not be processed until a valid US Social Security Number is received
C Photograph ndash In a sealed envelope include one 2rdquo X 2rdquo front view head and shoulders photograph of yourself Please sign your name on the back of the photograph This picture must be current
D Fingerprints ndash See enclosed ldquoIMPORTANT FINGERPRINT INFORMATION The Board requires a Department of Justice (DOJ) and Federal Bureau of Investigation (FBI) criminal history background check on all applicants Note A LICENSE WILL NOT BE ISSUED UNTIL THE BOARD RECEIVES THE BACKGROUND INFORMATION FROM DOJ
E Fee ndash Attach a check for $15000 made payable to the ldquoBVNPTrdquo This is a non-refundable fee that covers the application process Do NOT send cash If you will be submitting the hard card fingerprints rather than live scan fingerprints you must also submit the $4900 fingerprint processing fees (See Important Fingerprint Information enclosed)
F Proof of 12th Grade Education ndash Attach proof of 12th grade education or its equivalent A copy of your high school diploma or GED Certificate is acceptable
G Record of Conviction (55A-6) ndash Complete and sign the Record of Conviction Failure to complete this form accurately may delay the processing of your application
H Postcard (55A-7) ndash Write your name and address on the postcard provided Make sure to place a postage stamp on the postcard to receive verification that your application was received by the Board (Note Not applicable for applications downloaded from the internet)
I Other Required Documents ndash See Step 2 and your specific method of qualifying to ascertain any other documents which must be submitted for examination and licensure
55A-8(032012)
STEP 2
SUMMARY OF REQUIREMENTS FOR LICENSURE ndash Read the enclosed ldquoSummary of Requirements for Licensure (Form 55A-9)rdquo to determine which method may qualify you for the Vocational Nurse examination and licensure Follow the instructions below for the method by which you qualify
Method 1 ndash Graduates of California Accredited Schools of Vocational Nursing in California
Instructions are on file with each school Applications must be submitted by the Director of your Nursing Program Contact your program director for application instructions
Method 2 ndash Graduates of an Out-of-State School of PracticalVocational Nursing
Submit all items listed in Step 1 on the first page of these instructions Record of Nursing Program and Official Transcripts (Form 55A-2) - Send this form to your school of
practicalvocational nursing for completion and request that the school return the completed form to you with an official certified transcript in a sealed business envelope You must submit the sealed business envelope containing the Record of Nursing Program and official transcripts with your application for licensure
Method 3 ndash Equivalent Education andor Experience
Submit all items listed in Step 1 on the first page of these instructions In addition you must submit the following documentation with your application for licensure
- Record of Nursing Program and Official Transcripts (Form 55A-2) ndash If you attended nursing school send this form to your school for completion and request that the school return the completed form to you with an official certified transcript in a sealed business envelope Transcripts received from the school in a foreign language will also require a certified English-language translation completed either by the school or by an independent professional translator who is not related to the applicant You must submit the sealed business envelope containing the Record of Nursing Program and official transcripts with your application for licensure
- Record of Nursing Experience (Form 55A-3) - Complete this form and submit it with your application for licensure
- Employment Verification ndash Nursing Experience (Form 55A-12) ndash Complete Part I of this form Provide copies to all of the employers that you listed on the Record of Nursing Experience (you may reproduce as many copies as needed) The RN Director or Supervisor must complete the remainder of the form and return it to you in a sealed business envelope You must submit the UNOPENED sealed business envelope(s) containing the completed Employment Verification Forms with your application for licensure
- Proof of 54 Theory Hours of Pharmacology ndashVerification of 54 theory hours of pharmacology may be submitted on the Record of Nursing Program or a copy of the Course Completion Certificate specifying completion of 54 theory hours of pharmacology and the grade earned You must submit the sealed business envelope containing the Record of Nursing Program or Course Completion Certificate with your application for licensure (See Summary of Requirements for Licensure as a Vocational Nurse (Form 55A-9) for required course content)
2
Method 4 ndash Military Applicants
Submit all items listed in Step 1 on the first page of these instructions
Record of Military Service (Form 55A-4) - Complete this form in full
In addition you must submit 1 Copies of military service evaluations showing the dates of service wards assigned and duties
performed for each assignment You must demonstrate that you rendered at least twelve (12) months of active duty bedside patient care
2 Transcripts or ldquoCertificate of Release or Discharge from Active Dutyrdquo (DD214) showing completion of basic course of instruction in nursing required by his or her particular branch of the Armed Forces
3 DD214 or other military document showing that service in the Armed Forces has been under honorable conditions or whose general discharge has been under honorable conditions
Currently Licensed as a PracticalVocational Nurse in Another State
If you are currently licensed as a PracticalVocational Nurse in another US State or territory you have received the wrong application package Please contact the Board at (916) 263-7800 and request an Application for Licensure by Endorsement
IMPORTANT INFORMATION Address Change If you change your address after submitting your application for licensure you must notify the Board in writing immediately but no
later than thirty (30) days from the date of the address change
Application Materials The documents you submit will not be returned to you The Record of Nursing Program must be completed by the Director of your educational program and accompanied by an official certified
transcript These documents must be submitted to the Board with your application in an unopened sealed business envelope from the school
Only official transcripts are acceptable (photocopies are not accepted) Official transcripts must list subjects and hours (theory and clinical) completed and the grades received for each subject area Foreign transcripts must be accompanied by a certified translation if not in English
Employment verification forms must be submitted with your application in an unopened sealed business envelope Employment verification forms that appear to have been opened andor altered will not be accepted
Fees The fees for evaluation of your application and processing your fingerprint cards are non -refundable In addition please be advised
that the fingerprint processing fees are subject to change without notice by the DOJ and FBI All applicants for licensure by examination are required to attach a check or money order made payable to the ldquoBVNPTrdquo with their application Please do not send cash
APPLICATION FOR LICENSURE BY EXAMINATION FEE Application Fee $15000
FINGERPRINT PROCESSING FEES FBI Fingerprint Card Processing Fee $1700 DOJ Fingerprint Card Processing Fee $3200
$4900
RETAKE APPLICATION FOR LICENSURE BY EXAMINATION FEE Application Fee $15000
NCLEXreg REGISTRATION After the Board has determined your eligibility for examination you will be mailed a National Council Licensure Examination (NCLEXreg) Candidate Bulletin which contains the examination registration information You must submit a completed NCLEXreg
Registration form and NCLEXreg Registration Fee to the Data Center each time you apply to take the examination See ldquoNCLEX Registration Processrdquo below for details
NCLEXreg Registration Fee $20000
3
INITIAL LICENSE FEE When all requirements for licensure have been met the Board will advise you of the Initial License Fee to be paid This fee is in addition to the application evaluation fee
Filing DeadlinesProcessing Times Applications are accepted on a year-round basis There are no specific filing deadlines However appointments for testing are made
on a first-come first-serve basis You are encouraged to file your application for examination at least three (3) months prior to your anticipated testing da te to allow
sufficient time for evaluation It takes approximately eight (8) weeks for initial processing You will be notified at that time if additional information is needed to complete the evaluation of your application
Name Change If you change your name please notify the Board in writing and attach a copy of one (1) of the following documents Marriage Certificate Divorce Decree Passport or Driverrsquos License
NCLEXreg Registration Process After the Board has determined your eligibility for examination you will be mailed a National Council Licensure Examination
(NCLEXreg) Candidate Bulletin which contains the examination registration information Eligible candidates must register with the NCLEX Data Center within 180 days (6 months) of this notification
The NCLEXreg Registration procedures are
Registration by Mail a Complete the Registration Application Form b Attach a money order or cashierrsquos check for $20000 made payable to ldquoNCSBNrdquo c Mail the Registration Application Form and fee to the NCLEXreg Data Center
Registration by Telephone a Complete the Registration Application Form b Call the NCLEXreg Data Center Directly using the toll free number on the application form c Provide the operator with all of the information contained on the Registration Application Form d Provide the operator with your VISA or MasterCard credit card number and expiration date The registration fee is $20000
Registration by Internet a For internet registration go to wwwvuecomnclex and follow the instructions provided The registration fee is $20000
Scheduling Your Appointment to Test When NCLEXreg Data Center has processed your registration and verified your eligibility with the Board the NCLEXreg Data Center will
mail you an ldquoAuthorization to Testrdquo along with a list of Testing Centers
Select the Testing Center most convenient for you Call that Testing Center and schedule your appointment to take the test
The Testing Center is required to ensure that all eligible first-time applicants are scheduled within thirty (30) days of their requested test date In addition all eligible repeat applicants will be scheduled within forty-five (45) days of their requested test date
Special Accommodations for Disabled Candidates Special testing accommodations are available for candidates with disabilities Disabled candidates must notify the Board prior to
scheduling an appointment to test to obtain the requirements for requesting special accommodations
Disclosure of your Social Security Number is mandatory Section 30 of the Business and Professions Code and Public Law 94shy455 [(42 USCA (c) (2) (C))] authorize collection of your Social Security Number Your Social Security Number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your Social Security Number your application for initial license will not be processed and you will be reported to the Franchise Tax Board
The DOJ currently requires live scan fingerprint services for California residents Applicants submitting live scan fingerprints will be required to pay the fingerprint processing fees at the live scan station All applicants residing out-of-state must submit hard card fingerprints If you reside outside of California and will be submitting the hard card fingerprints rather than live scan fingerprints you must include the $4900 fingerprint processing fees with your fingerprint cards The fingerprint processing fees may be combined with the application fee and submitted to the Board on one check or money order made payable to the BVNPT (see Important Fingerprint Information enclosed)
Retake applicants are not required to submit fingerprint cards and the applicable processing fees unless they have not previously satisfied this requirement or the original application was abandoned Applicants are only required to submit fingerprints and associated processing fees one time
4
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
SUMMARY OF REQUIREMENTS FOR LICENSURE AS A VOCATIONAL NURSE
ALL APPLICANTS FOR LICENSURE AS A VOCATIONAL NURSE IN CALIFORNIA MUST MEET ALL OF THE REQUIREMENTS UNDER SECTION A AND ONE OF THE FOUR METHODS OF QUALIFYING FOR EXAMINATION IN SECTION B
SECTION A
1 BE AT LEAST 17 YEARS OF AGE
2 FURNISH PROOF OF COMPLETION OF THE 12TH GRADE OF SCHOOLING OR ITS EQUIVALENT
3 COMPLETE AND SIGN THE ldquoAPPLICATION FOR VOCATIONAL NURSE LICENSURErdquo AND FURNISH A VALID US SOCIAL SECURITY NUMBER
4 COMPLETE AND SIGN THE ldquoRECORD OF CONVICTIONrdquo FORM
5 NOT BE SUBJECT TO DENIAL PURSUANT TO BUSINESS amp PROFESSIONS CODE SECTION 480
6 SUBMIT THE REQUIRED DEPARTMENT OF JUSTICE (DOJ) AND FEDERAL BUREAU OF INVESTIGATION (FBI) FINGERPRINTS (SEE ENCLOSED ldquoIMPORTANT FINGERPRINT INFORMATIONrdquo) NOTE A LICENSE WILL NOT BE ISSUED UNTIL THE BOARD RECEIVES THE BACKGROUND INFORMATION FROM DOJ
7 ATTACH THE APPROPRIATE NONREFUNDABLE FEE MADE PAYABLE TO THE ldquoBVNPTrdquo (SEE PAGE 3 OF ENCLOSED ldquoINSTRUCTIONS TO APPLICANTS FOR LICENSURE AS A LICENSED VOCATIONAL NURSE)
8 SUCCESSFULLY COMPLETE A WRITTEN EXAMINATION TITLED ldquoNATIONAL COUNCIL LICENSING EXAMINATION FOR PRACTICAL (VOCATIONAL) NURSING (NCLEX PN)rdquo OR THE ldquoNATIONAL LEAGUE FOR NURSING TEST POOL PRACTICAL NURSING EXAMINATION (NLN)rdquo A PASSING SCORE ON A REGISTERED NURSE EXAMINATION WILL NOT SATISFY THIS REQUIREMENT
9 SUBMIT THE INITIAL LICENSE FEE WHEN YOU QUALIFY FOR LICENSURE THE BOARD WILL ADVISE YOU OF THE INITIAL LICENSE FEE TO BE PAID THIS FEE IS IN ADDITION TO THE APPLICATION FEE IT TAKES 4-6 WEEKS TO PROCESS YOUR LICENSE ONCE THIS FEE HAS BEEN RECEIVED
SECTION B - TO BE DEEMED ELIGIBLE FOR EXAMINATION YOU MUST QUALIFY BY ONE OF THE FOLLOWING METHODS
1 GRADUATE OF A CALIFORNIA ACCREDITED SCHOOL OF VOCATIONAL NURSING
YOU MUST HAVE SUCCESSFULLY COMPLETED A CALIFORNIA ACCREDITED VOCATIONAL NURSING PROGRAM
2 GRADUATE OF AN OUT-OF-STATE SCHOOL OF PRACTICALVOCATIONAL NURSING
THE SCHOOL OF PRACTICALVOCATIONAL NURSING FROM WHICH YOU GRADUATED MUST HAVE BEEN ACCREDITED BY THE BOARD OF NURSING IN THE STATE IN WHICH IT IS LOCATED AND THE COURSE CONTENT MUST HAVE BEEN SUBSTANTIALLY EQUIVALENT TO CALIFORNIA CURRICULUM REQUIREMENTS
LICENSURE IN ANOTHER STATE DOES NOT ENTITLE YOU TO PRACTICE AS A LICENSED VOCATIONAL NURSE IN CALIFORNIA IN ORDER TO PRACTICE AS A LICENSED VOCATIONAL NURSE IN CALIFORNIAYOU MUST BE LICENSED BY THE CALIFORNIA STATE BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS
55A-9 (108)
3 EQUIVALENT EDUCATION ANDOR EXPERIENCE
THIS METHOD REQUIRES YOU TO COMPLETE WITHIN TEN (10) YEARS PRIOR TO THE DATE OF APPLICATION NOT LESS THAN FIFTY-ONE (51) MONTHS OF PAID GENERAL DUTY INPATIENT BEDSIDE NURSING EXPERIENCE IN A CLINICAL FACILITY AT LEAST HALF OF WHICH SHALL HAVE BEEN WITHIN FIVE (5) YEARS PRIOR TO THE DATE OF APPLICATION PAID GENERAL DUTY INPATIENT BEDSIDE NURSING EXPERIENCE IS THE PERFORMANCE OF DIRECT PATIENT CARE FUNCTIONS PROVIDED THROUGHOUT THE PATIENTrsquoS STAY THAT ENCOMPASS THE BREADTH AND DEPTH OF EXPERIENCE EQUIVALENT TO THAT PERFORMED BY THE LICENSED VOCATIONAL NURSE YOU MUST ALSO COMPLETE A PHARMACOLOGY COURSE OF AT LEAST 54 THEORY HOURS
A THE PHARMACOLOGY COURSE (54 THEORY HOURS) SHALL INCLUDE BUT IS NOT LIMITED TO KNOWLEDGE OF COMMONLY USED DRUGS AND THEIR ACTION COMPUTATION OF DOSAGES PREPARATION OF MEDICATIONS PRINCIPLES OF ADMINISTRATION
B THE 51 MONTHS OF EXPERIENCE SHALL INCLUDE A MINIMUM OF EACH OF THE FOLLOWING 48 MONTHS MEDICALSURGICAL NURSING 6 WEEKS MATERNITY OR GENITOURINARY NURSING 6 WEEKS PEDIATRIC NURSING
C EXPERIENCE IN ANY OF THE FOLLOWING AREAS MAY BE SUBSTITUTED FOR A MAXIMUM OF EIGHT (8) MONTHS OF MEDICALSURGICAL EXPERIENCE
COMMUNICABLE DISEASE NURSING PRIVATE DUTY NURSING (IN AN ACUTE CARE FACILITY ONLY) PUBLIC HEALTH NURSING EMERGENCY ROOM NURSING OCCUPATIONAL HEALTH NURSING OUT PATIENT CLINIC OFFICE NURSING (MD) POST ANESTHESIA RECOVERY NURSING PSYCHIATRIC NURSING HEMODIALYSIS NURSING OPERATING ROOM NURSING REHABILITATION NURSING GERONTOLOGICAL NURSING EMERGENCY MEDICAL TECHNICIAN SERVICE
D EXPERIENCE MUST BE VERIFIED BY THE EMPLOYER SHOWING SPECIFIC DATES OF EMPLOYMENT AND SHALL INCLUDE CERTIFICATION FROM THE RN DIRECTOR OR SUPERVISOR THAT THE APPLICANT HAS SATISFACTORILY DEMONSTRATED THE FOLLOWING KNOWLEDGE AND SKILLS
1 BASIC BEDSIDE NURSING AMBULATION TECHNIQUES INTAKE AND OUTPUT BEDMAKING PERSONAL HYGIENE AND COMFORT MEASURES URINARY CATHETER CARE POSITIONING AND TRANSFER COLLECTION OF SPECIMENS RANGE OF MOTION DIABETIC TESTING SKIN CARE ADMINISTRATION OF A CLEANSING ENEMA VITAL SIGNS FEEDING PATIENT HOT AND COLD APPLICATIONS COMMUNICATION SKILLS BOTH VERBAL AND WRITTEN INCLUDING
COMMUNICATION WITH PATIENTS WHO HAVE PSYCHOLOGICAL DISORDERS
2 INFECTION CONTROL PROCEDURES (MAY BE DEMONSTRATED IN CLASSROOM LAB ANDOR PATIENT CARE SETTINGS)
ASEPSIS TECHNIQUES FOR STRICT CONTACT RESPIRATORY ENTERIC TUBERCULOSIS DRAINAGE UNIVERSAL AND
IMMUNOSUPPRESSED PATIENT ISOLATION
APPLICANTS WITH FORMAL NURSING EDUCATION MAY SUBMIT OFFICIAL TRANSCRIPTS FOR EVALUATION FOR POSSIBLE CREDIT IN LIEU OF PAID BEDSIDE NURSING EXPERIENCE THE TRANSCRIPTS MUST BE SUBMITTED TO THE BOARD DIRECTLY FROM THE SCHOOL AND MUST SHOW THEORY AND CLINICAL HOURS COMPLETED
4 NURSING SERVICE IN THE MEDICAL CORPS OF ANY BRANCH OF THE ARMED FORCES OF THE UNITED STATES THIS METHOD REQUIRES
A MILITARY SERVICE EVALUATIONS SHOWING AT LEAST TWELVE (12) MONTHS SERVICE ON ACTIVE DUTY IN THE MEDICAL CORPS OF ANY OF THE ARMED FORCES RENDERING BEDSIDE PATIENT CARE MILITARY SERVICE EVALUATIONS MUST BE SUBMITTED SHOWING THE DATES OF SERVICE WARDS ASSIGNED AND THE DUTIES PERFORMED FOR EACH ASSIGNMENT
B TRANSCRIPTS OR ldquoCERTIFICATE OF RELEASE OR DISCHARGE FROM ACTIVE DUTYrdquo (DD 214) SHOWING COMPLETION OF BASIC COURSE OF INSTRUCTION IN NURSING REQUIRED BY HIS OR HER PARTICULAR BRANCH OF THE ARMED FORCES
C DD 214 OR OTHER MILITARY DOCUMENT SHOWING THAT SERVICE IN THE ARMED FORCES HAS BEEN UNDER HONORABLE CONDITIONS OR WHOSE GENERAL DISCHARGE HAS BEEN UNDER HONORABLE CONDITIONS
NOTE A COMBINATION OF MILITARY AND NONMILITARY EXPERIENCE IS NOT ACCEPTABLE UNDER THIS METHOD PROOF OF 12TH
GRADE EDUCATION IS NOT REQUIRED UNDER THIS METHOD
NOTE STATE BOARDS OF NURSING IN MANY STATES REQUIRE GRADUATION FROM AN ACCREDITED SCHOOL OF NURSING PLEASE BE AWARE THAT APPLICANTS DEEMED ELIGIBLE FOR LICENSURE IN CALIFORNIA USING OTHER METHODS OF QUALIFYING (IE MILITARY EXPERIENCE OR EQUIVALENT EDUCATION AND EXPERIENCE) MAY NOT BE ELIGIBLE FOR LICENSURE BY ENDORSEMENT IN OTHER STATES
2
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
APPLICATION FOR VOCATIONAL NURSE LICENSURE
(ATTACH $150 APPLICATION FEE AN ADDITIONAL $49 FINGERPRINT FEE IS REQUIRED FOR PROCESSING ldquoHARD CARDrdquo FINGERPRINTS ndash SEE ENCLOSED INSTRUCTIONS )
Read all the enclosed instructions carefully before completing this application This information is required under Business and Professions Code Division 2 Chapter 65 Articles 1 and 2 The information you furnish will be used to determine your eligibility for licensure If additional space is needed to complete any section of this application please attach additional sheets The Executive Officer of the Board is responsible for information maintenance
PRINT OR TYPE (DO NOT USE PENCIL)
DO NOT WRITE IN THIS SPACE
APP NO
LIC NO
ILF-CA NO
ATS NO
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (MonthDayYear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBER Business (____)_________________________ Home (_____)_________________________
Area Code
7 DID YOU GRADUATE FROM HIGH SCHOOL YES NO NAME OF HIGH SCHOOL_______________________________ CITYSTATE_________________
DID YOU PASS A HIGH SCHOOL EQUIVALENCY TEST YES NO IF NO CIRCLE THE HIGHEST GRADE YOUCOMPLETED 1 2 3 4 5 6 7 8 9 10 11 12
8 DID YOU ATTEND A VOCATIONALPRACTICAL NURSING PROGRAM YES NO DID YOU GRADUATE FROM THE PROGRAM YES NO IF YES NAME OF VOCATIONALPRACTICAL NURSING PROGRAM DATE STARTED DATE COMPLETED STATE OR COUNTRY
_________________________________________________________ ________________ __________________ ___________________
9 DID YOU ATTEND A REGISTERED NURSING PROGRAM YES NO DID YOU GRADUATE FROM THE PROGRAM YES NO IF YES NAME OF REGISTERED NURSING PROGRAM DATE STARTED DATE COMPLETED STATE OR COUNTRY
_________________________________________________________ ________________ __________________ ________________
10 HAVE YOU EVER BEEN LICENSED AS A VOCATIONALPRACTICAL NURSE YES NO DATE LICENSED___________ STATE OF ORIGINAL LICENSE______
IF YES HAS THIS LICENSE EVER BEEN SUSPENDED REVOKED OR PLACED ON PROBATION YES NO (IF YES ATTACH EXPLANATION)
11 HAVE YOU EVER BEEN LICENSED AS A REGISTERED NURSE YES NO DATE LICENSED____________STATE OF ORIGINAL LICENSE____________
IF YES HAS THIS LICENSE EVER BEEN SUSPENDED REVOKED OR PLACED ON PROBATION YES NO (IF YES ATTACH EXPLANATION)
12 HAVE YOU EVER APPLIED TO THIS BOARD FOR LICENSURE UNDER A DIFFERENT NAME YES NO IF ldquoYESrdquo PLEASE LIST OTHER NAMES
WILL DOCUMENTS BE SUBMITTED TO THIS BOARD UNDER A DIFFERENT NAME YES NO IF YES PLEASE LIST OTHER NAMES
13 CONFIDENTIALITY NOTICE YOU ARE ADVISED THAT PURSUANT TO BUSINESS AND PROFESSIONS CODE SECTION 123 THE CONTENT OF THE VOCATIONAL NURSE LICENSURE EXAMINATION IS CONFIDENTIAL IF YOU ARE DEEMED ELIGIBLE TO TAKE THIS EXAMINATION YOU ARE HEREBY NOTIFIED THAT UNAUTHORIZED POSSESSION REPRODUCTION OR DISCLOSURE OF ANY EXAMINATION MATERIALS IS IN VIOLATION OF THE LAW AND SUBJECT TO CRIMINAL MISDEMEANOR PROSECUTION A VIOLAT ION OF THIS TYPE MAY ALSO RESULT IN CIVIL LIABILITY ANDOR DISCIPLINE BY THE LICENSING AGENCY INCLUDING THE DENIAL OF LICENSURE
14 PHOTOGRAPH REQUIREMENTS YOU MUST ATTACH A CURRENT FRONT VIEW HEAD AND SHOULDER PHOTOGRAPH OF YOURSELF IN A SEALED ENVELOPE THE PHOTOGRAPH SHOULD BE 2rdquo X 2rdquo AND MUST BE SIGNED ON THE BACK
15 PLEASE READ CAREFULLY BEFORE SIGNING ndash I hereby certify under penalty of perjury under the laws of the State of California that
the foregoing including any attachments is true and correct False statements included in this application can result in licensure denial
SIGNATURE_____________________________________________________________________ DATE___________ _____________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your Social Security Number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [(42 USCA (c ) (2) (C))] authorizes collection of your Social Security Number Your Social Security Number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your Social Security Number your application for initial license will not be processed and you will be reported to the Franchise Tax Board which may assess a $100 penalty against you
55A-1 (0312)
____
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
RECORD OF NURSING PROGRAM The applicant should complete the first section of this form and provide it to the Director of the nursing program The Director of the nursing program should complete the information in the second section and return it to the above address
THIS SECTION TO BE COMPLETED BY APPLICANT (ITEMS 1-6) PRINT OR TYPE (DO NOT USE PENCIL) 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (MonthDayYear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBERS BUSINESS ( )_________________________________ HOME ( )_________________________________
AREA CODE
THIS SECTION TO BE COMPLETED BY SCHOOLS OF VOCATIONAL PRACTICAL OR REGISTERED NURSING PRINT OR TYPE (DO NOT USE PENCIL)
7 NAME OF SCHOOL OF VOCATIONAL OR PRACTICAL NURSING CITY STATE
______________________________________________________________________ ______________________________________________________
DATE PROGRAM STARTED______________DATE PROGRAM COMPLETED______________ OR DATE VERIFIED HOURS WERE COMPLETED________________
WAS PROGRAM ldquoACCREDITEDrdquo WHEN HOURS WERE COMPLETED YES NO
8 NAME OF SCHOOL OF REGISTERED NURSING CITY STATE
_______________________________________________________________________ _______________________________________________________
DATE PROGRAM STARTED_____________ DATE PROGRAM COMPLETED_______________ OR DATE VERIFIED HOURS WERE COMPLETED________________
WAS PROGRAM ldquoACCREDITEDrdquo WHEN HOURS WERE COMPLETED YES NO
9 COMPLETION OF THE TW ELFTH (12TH) GRADE IN HIGH SCHOOL OR ITS EQUIVALENT HAS BEEN PROVEN BY THE APPLICANT AS FOLLOW S
PRESENTED OFFICIAL SCHOOL RECORDS SHOWING COMPLETION OF 12TH GRADE HIGH SCHOOL
PASSED THE ldquoGEDrdquo TEST AT THE 12TH GRADE LEVEL
10 A TOTAL NUMBER OF THEORYCLINICAL HOURS COMPLETED IN YOUR NURSING PROGRAM
THEORY__________HOURS CLINICAL__________HOURS
B TOTAL NUMBER OF THEORYCLINICAL HOURS WHICH YOUR SCHOOL GRANTED CREDIT FOR ldquoPREVIOUS EDUCATIONrdquo
THEORY__________HOURS CLINICAL__________HOURS
C COMPLETE THE SECOND PAGE OF THIS FORM IN FULL THIS IS A MANDATORY REQUIREMENT
11 I CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
SIGNATURE OF PROGRAM DIRECTOR_____________________________________________
(SCHOOL SEAL) PRINT PROGRAM DIRECTORrsquoS NAME_____________________________________________
DATE________________________________________________________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your social security number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [(42 USCA (c)(2)(C))] authorizes collection of your social security number Your social security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your social security number your application for initial license will not be processed and you will be reported to the Franchise Tax Board
55A-2 (208)
RECORD OF NURSING PROGRAM THIS SECTION OF THE FORM MUST BE COMPLETED IN FULL
1 NAME OF SCHOOL OF NURSING
___________________________________________________________
CHECK ONE
VOCATIONALPRACTICAL NURSING PROGRAM
REGISTERED NURSING PROGRAM
2 CITY 3 STATE AND COUNTRY
4 DATE PROGRAM STARTED ____________________________________
(MONTHDAYYEAR)
5 DATE VERIFIED HOURS WERE COMPLETED____________________________
(MONTHDAYYEAR)
6 SUBJECT ACTUAL HOURSUNITS COMPLETED CHECK HERE
IF SUBJECT IS
INTEGRATED
GRADE RECEIVED HOURSUNITS OF CREDIT GRANTED FOR PREVIOUS
LEARNING
THEORY CLINICAL THEORY CLINICAL THEORY CLINICAL
ANATOMY amp PHYSIOLOGY NA NA NA
NUTRITION NA NA NA
PHARMACOLOGY NA NA NA
PSYCHOLOGY NA NA NA
NORMAL GROWTH amp DEVELOPMENT
NA NA NA
NURSING FUNDAMENTALS
NURSING PROCESS
MEDICAL SURGICAL NURSING
COMMUNICABLE DISEASES
MATERNITY NURSING
PEDIATRIC NURSING
GERONTOLOGICAL NURSING
REHABILITATION NURSING
LEADERSHIP NA NA NA
SUPERVISION NA NA NA
COMMUNICATION NA NA NA
PATIENT EDUCATION NA NA NA
ETHICS amp UNETHICAL CONDUCT NA NA NA
CRITICAL THINKING NA NA NA
CULTURALLY CONGRUENT CARE
END OF LIFE CARE
TOTAL HOURS
____
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
RECORD OF NURSING EXPERIENCE PRINT OR TYPE (DO NOT USE PENCIL)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (monthdayyear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBERS BUSINESS ( )_________________________________ HOME ( )_________________________________
AREA CODE
EXPERIENCE List all nursing experience for the past ten (10) years for which you will be submitting verification of employment It is your responsibility to contact each employer and provide them with a copy of the Employment Verification ndash Nursing Experience Form for completion
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
_________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7B Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From _________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From _________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
NOTE IF MORE SPACE IS NEEDED PLEASE COMPLETE THE SECOND PAGE OF THIS FORM PLEASE READ CAREFULLY BEFORE SIGNING ndash I hereby certify under penalty of perjury under the laws of the State of California that the information
herein including any attachments is true and correct False statements included in this application can result in licensure denial
SIGNATURE_____________________________________________________________________ DATE________________________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your social security number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [42 USCA (c)(2)(C)] authorizes collection of your social security number Your social security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your social security number your application for initial license will not be processed and you will be reported to the Franchise Tax Board which may assess a $100 penalty against you
55A-3(408) 1
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
__________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7E Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7F Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7G Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7H Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7I Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
2
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROW N JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
In order to receive credit for nursing experience State law requires that the Board obtain verification of employment and certification from the Registered Nurse (RN) Director or Supervisor that the applicant has demonstrated the required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
INSTRUCTIONS TO APPLICANT
Complete Part I on the second page of this form and provide a copy of both pages to each employer for the past ten (10) years (You may reproduce as many copies of this form as needed)
This form must be completed in full by the RN Director or Supervisor and returned directly to you in the employerrsquos sealed business envelope The UNOPENED sealed envelopes containing the Employment Verification Forms must be submitted to the Board with your Application for Vocational Nurse Licensure
If you already have an application on the file with the Board and are submitting additional experience the employment verification form may be submitted to the Board by the applicant or the employer but must be received in the employerrsquos sealed business envelope
Please be advised that employment verification forms that appear to have been opened or altered will not be accepted The Board conducts random audits to verify the accuracy of the information submitted Discrepancies or false statements included in the application can result in licensure denial
INSTRUCTIONS TO EMPLOYER
The applicant on page two of this form is applying for licensure as a vocational nurse under Section 2873 of the Business and Professions Code In order for the applicant to receive credit for nursing experience State law requires the Board to obtain verification of employment and certification from the RN Director or Supervisor that the applicant has demonstrated required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
Please complete Parts II III and IV on page two of this form and return it to the applicant in a sealed business envelope Indicate on the outside of the envelope ldquoEmployment Verification Enclosed ndash Do Not Openrdquo It is the applicantrsquos responsibility to collect the Employment Verification Form(s) and submit them with the application for licensure
Part II Indicate the name and type of facility where the experience was obtained Part III Provide the specific dates that the applicant worked under your supervision in the area of
nursing being verified Additionally indicate if the applicant was employed full time (40 hrswk) or part time and include the number of hours worked in each area The Board MUST receive a breakdown of the number of hours spent in each area in order to evaluate the experience
Part IV Indicate whether the applicant has satisfactorily demonstrated each of the knowledge and skills with safety to the patient The skills listed in Part IV(B) may be demonstrated in classroom lab andor patient care settings
Thank you for your assistance Please feel free to contact the Board at (916) 263-7800 if you have any questions
55A-12 (Rev 1007) 1
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
Part I is to be completed by the applicant and submitted to employers for verification of nursing experience The remainder of this form must be completed by the RN Director or Supervisor and returned to the applicant by the employer in a sealed business envelope FORMS CONTAINING STRIKEOUTS OR CORRECTIONS WILL NOT BE ACCEPTED (See Page 1 for detailed instructions on how to complete this form)
Part I To be completed by the Applicant (print or type - do not use pencil)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 NAME WHILE EMPLOYED AT THIS FACILITY 5 SOCIAL SECURITY NUMBER
NOT required but may assist employer in locating records
6 DAYTIME TELEPHONE NUMBER
( )_________________________________ Area Code
Part II To be completed by the Employer - Indicate the name and type of facility where the experience was obtained
Name of facility where experience was obtained
Type of facility Acute or sub-acute(hospital) Home Health
Convalescent Skilled NursingLong Term Care Outpatient Clinicemergency care Other
Assisted Living
Part III To be completed by the Employer - Include dates and the area of nursing being verified Indicate if employment was full-time (40 hrswk) or part-time and include the total number of hours worked in each area
Areas of Bedside Nursing Experience Employment Period (MonthDateYear) Hours Worked
Per Week Total Hours In Each Area
For Office Use Only
Medical-Surgical Nursing From To Pediatric Nursing From To Maternity Nursing From To Genitourinary Nursing From To Psychiatric Nursing From To Office Nursing From To Long Term CareConvalescent From To Private Duty (in a general acute care facility) From To Other From To
Part IV To be completed by the Employer - Indicate if the applicant has satisfactorily demonstrated the following knowledge and skills with safety to the patient
Knowledge and Skills Demonstrated Knowledge and Skills Demonstrated YES NO YES NO
A Basic Bedside Nursing 1 Ambulation Techniques 9 Intake and Output 2 Bedmaking 10 Personal Hygiene and Comfort Measures 3 Urinary Catheter Care 11 Positioning and Transfer 4 Collection of Specimens 12 Range of Motion 5 Diabetic Testing 13 Skin Care 6 Administration of a Cleansing Enema 14 Vital Signs 7 Feeding Patient 15 Communication Skills Both Verbal and
Written Including Communication With Patients Who Have Psychological Disorders
8 Hot and Cold Applications
B Infection Control Procedures (may be demonstrated in classroom lab andor patient care settings) 1 Asepsis 2 Techniques for strict contact respiratory
enteric tuberculosis drainage universal and immunosuppressed patient isolation
TO BE SIGNED BY THE RN DIRECTOR OR SUPERVISOR I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
Signature ___________________________________________ Print Name___________________________________ Nursing License ___________________Exp Date__________ Telephone Number (_____)_ ____________________ Address _____________________________________________ Todayrsquos Date ________________________________ CityState ___________________________ Zip Code_______
55A-12 (Rev 1007) 2 Date Evaluated ____________ Initials ______
55A-6 (1015) - CONTINUED ON REVERSE -
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS RECORD OF CONVICTION
TYPE OR PRINT (USE BLUE OR BLACK INK ONLY) IF MORE SPACE IS NEEDED TO COMPLETE ANY SECTION PLEASE ATTACH ADDITIONAL SHEETS 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APARTMENT NUMBER)
3 CITY STATE ZIP
4 BIRTHDATE (MMDDYYYY) 6 TELEPHONE NUMBERS
CELL (_______) ________________________________________
HOME (_______) ________________________________________
BUSINESS (_______) ________________________________________
5 SOCIAL SECURITY OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER
7 Pursuant to Business and Professions Code Section 480 (c) any false statements included in this application may result in license denial Please carefully read all information contained on the front and back of this form before signing I declare under penalty of perjury under the laws of the State of California that the information provided herein and attachments is true and correct Signature ____________________________________________________________ Date ____________________________________
8 Are you or have you previously been licensed or certified as a psychiatric technician practical vocational or registered nurse or any other healthcare professional in this or any other state territory or country
Yes No
A
State
License Type
License
Expiration Date
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
B Has your license or certification ever been suspended revoked placed on probation or disciplined If Yes you must explain the basis for the disciplinary action and submit a copy of the disciplinary order
Yes No
C Have you used any other names If Yes list all other names used _______________________________________________________________
Yes No
9 Have you ever been convicted of pled guilty to or pled nolo contendere to ANY offense in the United States or a foreign country If YES you must complete item 12 on the back of this form
This includes every citation infraction misdemeanor andor felony excluding traffic violations under $1000 which do not involve alcohol dangerous drugs or controlled substances Convictions that were adjudicated in the juvenile court or convictions under California Health and Safety Code Sections 11357(b) (c) (d) (e) or Section 11360(b) which are two years or older should NOT be reported Convictions that were later dismissed pursuant to section 12034 12034a or 120341 of the California Penal Code or equivalent non-California law MUST be disclosed If you have obtained a dismissal of your conviction(s) pursuant to Penal Code sections 12034 12034(a) or 120341 please submit a certified copy of the court order dismissing the conviction(s) with your application
Yes No
10 Exclusive of juvenile court adjudications and criminal charges dismissed under section 10003 of the California Penal Code or equivalent non-California laws or convictions two years or older under California Health and Safety Code Sections 11357(b) (c) (d) (e) or section 11360(b) have you had a conviction that was set aside or later expunged from the records of the court If YES you must complete item 12 on the back of this form
Yes No
11 Is any court action pending against you or are you currently awaiting judgment and sentencing following entry of a plea or jury verdict If YES you must complete item 12 on the back of this form
Yes No
Important note You will be permitted to take the licensing examination regardless of any criminal conviction history you disclose However a determination as to whether your license will be granted or denied will not be made until you have passed the examination and the board has received all required conviction documentation
12 If you answered yes to item 9 10 or 11 you must provide all of the information requested below for each offense Department of Motor Vehicles printouts are not accepted in lieu of completing this section If more space is needed to complete this section please attach additional sheets
If you have been convicted of a crime you must submit certified court documents police reports and a detailed explanation in your own words for each offense (Certified courtpolice documents are obtained directly from the courtpolice department with an original stamp of certification Do not send copies as they will not contain an original certification and will not meet the requirement for certified documents If the police report andor court documents are no longer available you must obtain a statement from the police department or court attesting to that fact) Additionally please submit documents regarding your rehabilitation efforts such as
Proof that you complied with the terms of your parole probation restitution or any other court imposed sanctions Evidence of expungement proceedings pursuant to penal code section 12034 12034(a) or 120341 Any other evidence of rehabilitation you wish the board to consider
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
Notice on Collection of Personal Information For Applicants and Licensees
Collection and Use of Personal Information The Board of Vocational Nursing and Psychiatric Technicians (BVNPT) of the Department of Consumer Affairs (DCA) collects the personal information requested on this form as authorized by Business and Professions Code Section 30 (General Provisions) Business and Professions Code Division 2 Chapter 65 Articles 1 amp 2 (Vocational Nursing Practice Act) and Chapter 10 Articles 1 amp 2 (Psychiatric Technicians Law) and California Code of Regulations Title 16 Division 25 Chapter 1 (Vocational Nurses) and Chapter 2 (Psychiatric Technicians) The BVNPT uses this information principally to identify and evaluate applicants for licensure issue and renew licenses and enforce licensing standards set by law and regulation
Mandatory Submission Submission of the requested information is mandatory The BVNPT cannot consider your application for licensure or renewal unless you provide all of the requested information
Access to Personal Information You may review the records maintained by the BVNPT that contain your personal information as permitted by the Information Practices Act See below for contact information
Possible Disclosure of Personal Information The BVNPT makes every effort to protect the personal information you provide The information you provide however may be disclosed in the following circumstances
In response to a Public Records Act request (Government Code Section 6250 and following) as allowed by the Information Practices Act (Civil Code Section 1798 and following)
To another government agency as required or permitted by state or federal law or
In response to a court or administrative order a subpoena or a search warrant
Contact Information For questions about this notice or access to your records you may contact the BVNPT at 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833 (916) 263-7800 or email bvnptdcacagov
55P-1 (42109)
STEP 2
SUMMARY OF REQUIREMENTS FOR LICENSURE ndash Read the enclosed ldquoSummary of Requirements for Licensure (Form 55A-9)rdquo to determine which method may qualify you for the Vocational Nurse examination and licensure Follow the instructions below for the method by which you qualify
Method 1 ndash Graduates of California Accredited Schools of Vocational Nursing in California
Instructions are on file with each school Applications must be submitted by the Director of your Nursing Program Contact your program director for application instructions
Method 2 ndash Graduates of an Out-of-State School of PracticalVocational Nursing
Submit all items listed in Step 1 on the first page of these instructions Record of Nursing Program and Official Transcripts (Form 55A-2) - Send this form to your school of
practicalvocational nursing for completion and request that the school return the completed form to you with an official certified transcript in a sealed business envelope You must submit the sealed business envelope containing the Record of Nursing Program and official transcripts with your application for licensure
Method 3 ndash Equivalent Education andor Experience
Submit all items listed in Step 1 on the first page of these instructions In addition you must submit the following documentation with your application for licensure
- Record of Nursing Program and Official Transcripts (Form 55A-2) ndash If you attended nursing school send this form to your school for completion and request that the school return the completed form to you with an official certified transcript in a sealed business envelope Transcripts received from the school in a foreign language will also require a certified English-language translation completed either by the school or by an independent professional translator who is not related to the applicant You must submit the sealed business envelope containing the Record of Nursing Program and official transcripts with your application for licensure
- Record of Nursing Experience (Form 55A-3) - Complete this form and submit it with your application for licensure
- Employment Verification ndash Nursing Experience (Form 55A-12) ndash Complete Part I of this form Provide copies to all of the employers that you listed on the Record of Nursing Experience (you may reproduce as many copies as needed) The RN Director or Supervisor must complete the remainder of the form and return it to you in a sealed business envelope You must submit the UNOPENED sealed business envelope(s) containing the completed Employment Verification Forms with your application for licensure
- Proof of 54 Theory Hours of Pharmacology ndashVerification of 54 theory hours of pharmacology may be submitted on the Record of Nursing Program or a copy of the Course Completion Certificate specifying completion of 54 theory hours of pharmacology and the grade earned You must submit the sealed business envelope containing the Record of Nursing Program or Course Completion Certificate with your application for licensure (See Summary of Requirements for Licensure as a Vocational Nurse (Form 55A-9) for required course content)
2
Method 4 ndash Military Applicants
Submit all items listed in Step 1 on the first page of these instructions
Record of Military Service (Form 55A-4) - Complete this form in full
In addition you must submit 1 Copies of military service evaluations showing the dates of service wards assigned and duties
performed for each assignment You must demonstrate that you rendered at least twelve (12) months of active duty bedside patient care
2 Transcripts or ldquoCertificate of Release or Discharge from Active Dutyrdquo (DD214) showing completion of basic course of instruction in nursing required by his or her particular branch of the Armed Forces
3 DD214 or other military document showing that service in the Armed Forces has been under honorable conditions or whose general discharge has been under honorable conditions
Currently Licensed as a PracticalVocational Nurse in Another State
If you are currently licensed as a PracticalVocational Nurse in another US State or territory you have received the wrong application package Please contact the Board at (916) 263-7800 and request an Application for Licensure by Endorsement
IMPORTANT INFORMATION Address Change If you change your address after submitting your application for licensure you must notify the Board in writing immediately but no
later than thirty (30) days from the date of the address change
Application Materials The documents you submit will not be returned to you The Record of Nursing Program must be completed by the Director of your educational program and accompanied by an official certified
transcript These documents must be submitted to the Board with your application in an unopened sealed business envelope from the school
Only official transcripts are acceptable (photocopies are not accepted) Official transcripts must list subjects and hours (theory and clinical) completed and the grades received for each subject area Foreign transcripts must be accompanied by a certified translation if not in English
Employment verification forms must be submitted with your application in an unopened sealed business envelope Employment verification forms that appear to have been opened andor altered will not be accepted
Fees The fees for evaluation of your application and processing your fingerprint cards are non -refundable In addition please be advised
that the fingerprint processing fees are subject to change without notice by the DOJ and FBI All applicants for licensure by examination are required to attach a check or money order made payable to the ldquoBVNPTrdquo with their application Please do not send cash
APPLICATION FOR LICENSURE BY EXAMINATION FEE Application Fee $15000
FINGERPRINT PROCESSING FEES FBI Fingerprint Card Processing Fee $1700 DOJ Fingerprint Card Processing Fee $3200
$4900
RETAKE APPLICATION FOR LICENSURE BY EXAMINATION FEE Application Fee $15000
NCLEXreg REGISTRATION After the Board has determined your eligibility for examination you will be mailed a National Council Licensure Examination (NCLEXreg) Candidate Bulletin which contains the examination registration information You must submit a completed NCLEXreg
Registration form and NCLEXreg Registration Fee to the Data Center each time you apply to take the examination See ldquoNCLEX Registration Processrdquo below for details
NCLEXreg Registration Fee $20000
3
INITIAL LICENSE FEE When all requirements for licensure have been met the Board will advise you of the Initial License Fee to be paid This fee is in addition to the application evaluation fee
Filing DeadlinesProcessing Times Applications are accepted on a year-round basis There are no specific filing deadlines However appointments for testing are made
on a first-come first-serve basis You are encouraged to file your application for examination at least three (3) months prior to your anticipated testing da te to allow
sufficient time for evaluation It takes approximately eight (8) weeks for initial processing You will be notified at that time if additional information is needed to complete the evaluation of your application
Name Change If you change your name please notify the Board in writing and attach a copy of one (1) of the following documents Marriage Certificate Divorce Decree Passport or Driverrsquos License
NCLEXreg Registration Process After the Board has determined your eligibility for examination you will be mailed a National Council Licensure Examination
(NCLEXreg) Candidate Bulletin which contains the examination registration information Eligible candidates must register with the NCLEX Data Center within 180 days (6 months) of this notification
The NCLEXreg Registration procedures are
Registration by Mail a Complete the Registration Application Form b Attach a money order or cashierrsquos check for $20000 made payable to ldquoNCSBNrdquo c Mail the Registration Application Form and fee to the NCLEXreg Data Center
Registration by Telephone a Complete the Registration Application Form b Call the NCLEXreg Data Center Directly using the toll free number on the application form c Provide the operator with all of the information contained on the Registration Application Form d Provide the operator with your VISA or MasterCard credit card number and expiration date The registration fee is $20000
Registration by Internet a For internet registration go to wwwvuecomnclex and follow the instructions provided The registration fee is $20000
Scheduling Your Appointment to Test When NCLEXreg Data Center has processed your registration and verified your eligibility with the Board the NCLEXreg Data Center will
mail you an ldquoAuthorization to Testrdquo along with a list of Testing Centers
Select the Testing Center most convenient for you Call that Testing Center and schedule your appointment to take the test
The Testing Center is required to ensure that all eligible first-time applicants are scheduled within thirty (30) days of their requested test date In addition all eligible repeat applicants will be scheduled within forty-five (45) days of their requested test date
Special Accommodations for Disabled Candidates Special testing accommodations are available for candidates with disabilities Disabled candidates must notify the Board prior to
scheduling an appointment to test to obtain the requirements for requesting special accommodations
Disclosure of your Social Security Number is mandatory Section 30 of the Business and Professions Code and Public Law 94shy455 [(42 USCA (c) (2) (C))] authorize collection of your Social Security Number Your Social Security Number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your Social Security Number your application for initial license will not be processed and you will be reported to the Franchise Tax Board
The DOJ currently requires live scan fingerprint services for California residents Applicants submitting live scan fingerprints will be required to pay the fingerprint processing fees at the live scan station All applicants residing out-of-state must submit hard card fingerprints If you reside outside of California and will be submitting the hard card fingerprints rather than live scan fingerprints you must include the $4900 fingerprint processing fees with your fingerprint cards The fingerprint processing fees may be combined with the application fee and submitted to the Board on one check or money order made payable to the BVNPT (see Important Fingerprint Information enclosed)
Retake applicants are not required to submit fingerprint cards and the applicable processing fees unless they have not previously satisfied this requirement or the original application was abandoned Applicants are only required to submit fingerprints and associated processing fees one time
4
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
SUMMARY OF REQUIREMENTS FOR LICENSURE AS A VOCATIONAL NURSE
ALL APPLICANTS FOR LICENSURE AS A VOCATIONAL NURSE IN CALIFORNIA MUST MEET ALL OF THE REQUIREMENTS UNDER SECTION A AND ONE OF THE FOUR METHODS OF QUALIFYING FOR EXAMINATION IN SECTION B
SECTION A
1 BE AT LEAST 17 YEARS OF AGE
2 FURNISH PROOF OF COMPLETION OF THE 12TH GRADE OF SCHOOLING OR ITS EQUIVALENT
3 COMPLETE AND SIGN THE ldquoAPPLICATION FOR VOCATIONAL NURSE LICENSURErdquo AND FURNISH A VALID US SOCIAL SECURITY NUMBER
4 COMPLETE AND SIGN THE ldquoRECORD OF CONVICTIONrdquo FORM
5 NOT BE SUBJECT TO DENIAL PURSUANT TO BUSINESS amp PROFESSIONS CODE SECTION 480
6 SUBMIT THE REQUIRED DEPARTMENT OF JUSTICE (DOJ) AND FEDERAL BUREAU OF INVESTIGATION (FBI) FINGERPRINTS (SEE ENCLOSED ldquoIMPORTANT FINGERPRINT INFORMATIONrdquo) NOTE A LICENSE WILL NOT BE ISSUED UNTIL THE BOARD RECEIVES THE BACKGROUND INFORMATION FROM DOJ
7 ATTACH THE APPROPRIATE NONREFUNDABLE FEE MADE PAYABLE TO THE ldquoBVNPTrdquo (SEE PAGE 3 OF ENCLOSED ldquoINSTRUCTIONS TO APPLICANTS FOR LICENSURE AS A LICENSED VOCATIONAL NURSE)
8 SUCCESSFULLY COMPLETE A WRITTEN EXAMINATION TITLED ldquoNATIONAL COUNCIL LICENSING EXAMINATION FOR PRACTICAL (VOCATIONAL) NURSING (NCLEX PN)rdquo OR THE ldquoNATIONAL LEAGUE FOR NURSING TEST POOL PRACTICAL NURSING EXAMINATION (NLN)rdquo A PASSING SCORE ON A REGISTERED NURSE EXAMINATION WILL NOT SATISFY THIS REQUIREMENT
9 SUBMIT THE INITIAL LICENSE FEE WHEN YOU QUALIFY FOR LICENSURE THE BOARD WILL ADVISE YOU OF THE INITIAL LICENSE FEE TO BE PAID THIS FEE IS IN ADDITION TO THE APPLICATION FEE IT TAKES 4-6 WEEKS TO PROCESS YOUR LICENSE ONCE THIS FEE HAS BEEN RECEIVED
SECTION B - TO BE DEEMED ELIGIBLE FOR EXAMINATION YOU MUST QUALIFY BY ONE OF THE FOLLOWING METHODS
1 GRADUATE OF A CALIFORNIA ACCREDITED SCHOOL OF VOCATIONAL NURSING
YOU MUST HAVE SUCCESSFULLY COMPLETED A CALIFORNIA ACCREDITED VOCATIONAL NURSING PROGRAM
2 GRADUATE OF AN OUT-OF-STATE SCHOOL OF PRACTICALVOCATIONAL NURSING
THE SCHOOL OF PRACTICALVOCATIONAL NURSING FROM WHICH YOU GRADUATED MUST HAVE BEEN ACCREDITED BY THE BOARD OF NURSING IN THE STATE IN WHICH IT IS LOCATED AND THE COURSE CONTENT MUST HAVE BEEN SUBSTANTIALLY EQUIVALENT TO CALIFORNIA CURRICULUM REQUIREMENTS
LICENSURE IN ANOTHER STATE DOES NOT ENTITLE YOU TO PRACTICE AS A LICENSED VOCATIONAL NURSE IN CALIFORNIA IN ORDER TO PRACTICE AS A LICENSED VOCATIONAL NURSE IN CALIFORNIAYOU MUST BE LICENSED BY THE CALIFORNIA STATE BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS
55A-9 (108)
3 EQUIVALENT EDUCATION ANDOR EXPERIENCE
THIS METHOD REQUIRES YOU TO COMPLETE WITHIN TEN (10) YEARS PRIOR TO THE DATE OF APPLICATION NOT LESS THAN FIFTY-ONE (51) MONTHS OF PAID GENERAL DUTY INPATIENT BEDSIDE NURSING EXPERIENCE IN A CLINICAL FACILITY AT LEAST HALF OF WHICH SHALL HAVE BEEN WITHIN FIVE (5) YEARS PRIOR TO THE DATE OF APPLICATION PAID GENERAL DUTY INPATIENT BEDSIDE NURSING EXPERIENCE IS THE PERFORMANCE OF DIRECT PATIENT CARE FUNCTIONS PROVIDED THROUGHOUT THE PATIENTrsquoS STAY THAT ENCOMPASS THE BREADTH AND DEPTH OF EXPERIENCE EQUIVALENT TO THAT PERFORMED BY THE LICENSED VOCATIONAL NURSE YOU MUST ALSO COMPLETE A PHARMACOLOGY COURSE OF AT LEAST 54 THEORY HOURS
A THE PHARMACOLOGY COURSE (54 THEORY HOURS) SHALL INCLUDE BUT IS NOT LIMITED TO KNOWLEDGE OF COMMONLY USED DRUGS AND THEIR ACTION COMPUTATION OF DOSAGES PREPARATION OF MEDICATIONS PRINCIPLES OF ADMINISTRATION
B THE 51 MONTHS OF EXPERIENCE SHALL INCLUDE A MINIMUM OF EACH OF THE FOLLOWING 48 MONTHS MEDICALSURGICAL NURSING 6 WEEKS MATERNITY OR GENITOURINARY NURSING 6 WEEKS PEDIATRIC NURSING
C EXPERIENCE IN ANY OF THE FOLLOWING AREAS MAY BE SUBSTITUTED FOR A MAXIMUM OF EIGHT (8) MONTHS OF MEDICALSURGICAL EXPERIENCE
COMMUNICABLE DISEASE NURSING PRIVATE DUTY NURSING (IN AN ACUTE CARE FACILITY ONLY) PUBLIC HEALTH NURSING EMERGENCY ROOM NURSING OCCUPATIONAL HEALTH NURSING OUT PATIENT CLINIC OFFICE NURSING (MD) POST ANESTHESIA RECOVERY NURSING PSYCHIATRIC NURSING HEMODIALYSIS NURSING OPERATING ROOM NURSING REHABILITATION NURSING GERONTOLOGICAL NURSING EMERGENCY MEDICAL TECHNICIAN SERVICE
D EXPERIENCE MUST BE VERIFIED BY THE EMPLOYER SHOWING SPECIFIC DATES OF EMPLOYMENT AND SHALL INCLUDE CERTIFICATION FROM THE RN DIRECTOR OR SUPERVISOR THAT THE APPLICANT HAS SATISFACTORILY DEMONSTRATED THE FOLLOWING KNOWLEDGE AND SKILLS
1 BASIC BEDSIDE NURSING AMBULATION TECHNIQUES INTAKE AND OUTPUT BEDMAKING PERSONAL HYGIENE AND COMFORT MEASURES URINARY CATHETER CARE POSITIONING AND TRANSFER COLLECTION OF SPECIMENS RANGE OF MOTION DIABETIC TESTING SKIN CARE ADMINISTRATION OF A CLEANSING ENEMA VITAL SIGNS FEEDING PATIENT HOT AND COLD APPLICATIONS COMMUNICATION SKILLS BOTH VERBAL AND WRITTEN INCLUDING
COMMUNICATION WITH PATIENTS WHO HAVE PSYCHOLOGICAL DISORDERS
2 INFECTION CONTROL PROCEDURES (MAY BE DEMONSTRATED IN CLASSROOM LAB ANDOR PATIENT CARE SETTINGS)
ASEPSIS TECHNIQUES FOR STRICT CONTACT RESPIRATORY ENTERIC TUBERCULOSIS DRAINAGE UNIVERSAL AND
IMMUNOSUPPRESSED PATIENT ISOLATION
APPLICANTS WITH FORMAL NURSING EDUCATION MAY SUBMIT OFFICIAL TRANSCRIPTS FOR EVALUATION FOR POSSIBLE CREDIT IN LIEU OF PAID BEDSIDE NURSING EXPERIENCE THE TRANSCRIPTS MUST BE SUBMITTED TO THE BOARD DIRECTLY FROM THE SCHOOL AND MUST SHOW THEORY AND CLINICAL HOURS COMPLETED
4 NURSING SERVICE IN THE MEDICAL CORPS OF ANY BRANCH OF THE ARMED FORCES OF THE UNITED STATES THIS METHOD REQUIRES
A MILITARY SERVICE EVALUATIONS SHOWING AT LEAST TWELVE (12) MONTHS SERVICE ON ACTIVE DUTY IN THE MEDICAL CORPS OF ANY OF THE ARMED FORCES RENDERING BEDSIDE PATIENT CARE MILITARY SERVICE EVALUATIONS MUST BE SUBMITTED SHOWING THE DATES OF SERVICE WARDS ASSIGNED AND THE DUTIES PERFORMED FOR EACH ASSIGNMENT
B TRANSCRIPTS OR ldquoCERTIFICATE OF RELEASE OR DISCHARGE FROM ACTIVE DUTYrdquo (DD 214) SHOWING COMPLETION OF BASIC COURSE OF INSTRUCTION IN NURSING REQUIRED BY HIS OR HER PARTICULAR BRANCH OF THE ARMED FORCES
C DD 214 OR OTHER MILITARY DOCUMENT SHOWING THAT SERVICE IN THE ARMED FORCES HAS BEEN UNDER HONORABLE CONDITIONS OR WHOSE GENERAL DISCHARGE HAS BEEN UNDER HONORABLE CONDITIONS
NOTE A COMBINATION OF MILITARY AND NONMILITARY EXPERIENCE IS NOT ACCEPTABLE UNDER THIS METHOD PROOF OF 12TH
GRADE EDUCATION IS NOT REQUIRED UNDER THIS METHOD
NOTE STATE BOARDS OF NURSING IN MANY STATES REQUIRE GRADUATION FROM AN ACCREDITED SCHOOL OF NURSING PLEASE BE AWARE THAT APPLICANTS DEEMED ELIGIBLE FOR LICENSURE IN CALIFORNIA USING OTHER METHODS OF QUALIFYING (IE MILITARY EXPERIENCE OR EQUIVALENT EDUCATION AND EXPERIENCE) MAY NOT BE ELIGIBLE FOR LICENSURE BY ENDORSEMENT IN OTHER STATES
2
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
APPLICATION FOR VOCATIONAL NURSE LICENSURE
(ATTACH $150 APPLICATION FEE AN ADDITIONAL $49 FINGERPRINT FEE IS REQUIRED FOR PROCESSING ldquoHARD CARDrdquo FINGERPRINTS ndash SEE ENCLOSED INSTRUCTIONS )
Read all the enclosed instructions carefully before completing this application This information is required under Business and Professions Code Division 2 Chapter 65 Articles 1 and 2 The information you furnish will be used to determine your eligibility for licensure If additional space is needed to complete any section of this application please attach additional sheets The Executive Officer of the Board is responsible for information maintenance
PRINT OR TYPE (DO NOT USE PENCIL)
DO NOT WRITE IN THIS SPACE
APP NO
LIC NO
ILF-CA NO
ATS NO
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (MonthDayYear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBER Business (____)_________________________ Home (_____)_________________________
Area Code
7 DID YOU GRADUATE FROM HIGH SCHOOL YES NO NAME OF HIGH SCHOOL_______________________________ CITYSTATE_________________
DID YOU PASS A HIGH SCHOOL EQUIVALENCY TEST YES NO IF NO CIRCLE THE HIGHEST GRADE YOUCOMPLETED 1 2 3 4 5 6 7 8 9 10 11 12
8 DID YOU ATTEND A VOCATIONALPRACTICAL NURSING PROGRAM YES NO DID YOU GRADUATE FROM THE PROGRAM YES NO IF YES NAME OF VOCATIONALPRACTICAL NURSING PROGRAM DATE STARTED DATE COMPLETED STATE OR COUNTRY
_________________________________________________________ ________________ __________________ ___________________
9 DID YOU ATTEND A REGISTERED NURSING PROGRAM YES NO DID YOU GRADUATE FROM THE PROGRAM YES NO IF YES NAME OF REGISTERED NURSING PROGRAM DATE STARTED DATE COMPLETED STATE OR COUNTRY
_________________________________________________________ ________________ __________________ ________________
10 HAVE YOU EVER BEEN LICENSED AS A VOCATIONALPRACTICAL NURSE YES NO DATE LICENSED___________ STATE OF ORIGINAL LICENSE______
IF YES HAS THIS LICENSE EVER BEEN SUSPENDED REVOKED OR PLACED ON PROBATION YES NO (IF YES ATTACH EXPLANATION)
11 HAVE YOU EVER BEEN LICENSED AS A REGISTERED NURSE YES NO DATE LICENSED____________STATE OF ORIGINAL LICENSE____________
IF YES HAS THIS LICENSE EVER BEEN SUSPENDED REVOKED OR PLACED ON PROBATION YES NO (IF YES ATTACH EXPLANATION)
12 HAVE YOU EVER APPLIED TO THIS BOARD FOR LICENSURE UNDER A DIFFERENT NAME YES NO IF ldquoYESrdquo PLEASE LIST OTHER NAMES
WILL DOCUMENTS BE SUBMITTED TO THIS BOARD UNDER A DIFFERENT NAME YES NO IF YES PLEASE LIST OTHER NAMES
13 CONFIDENTIALITY NOTICE YOU ARE ADVISED THAT PURSUANT TO BUSINESS AND PROFESSIONS CODE SECTION 123 THE CONTENT OF THE VOCATIONAL NURSE LICENSURE EXAMINATION IS CONFIDENTIAL IF YOU ARE DEEMED ELIGIBLE TO TAKE THIS EXAMINATION YOU ARE HEREBY NOTIFIED THAT UNAUTHORIZED POSSESSION REPRODUCTION OR DISCLOSURE OF ANY EXAMINATION MATERIALS IS IN VIOLATION OF THE LAW AND SUBJECT TO CRIMINAL MISDEMEANOR PROSECUTION A VIOLAT ION OF THIS TYPE MAY ALSO RESULT IN CIVIL LIABILITY ANDOR DISCIPLINE BY THE LICENSING AGENCY INCLUDING THE DENIAL OF LICENSURE
14 PHOTOGRAPH REQUIREMENTS YOU MUST ATTACH A CURRENT FRONT VIEW HEAD AND SHOULDER PHOTOGRAPH OF YOURSELF IN A SEALED ENVELOPE THE PHOTOGRAPH SHOULD BE 2rdquo X 2rdquo AND MUST BE SIGNED ON THE BACK
15 PLEASE READ CAREFULLY BEFORE SIGNING ndash I hereby certify under penalty of perjury under the laws of the State of California that
the foregoing including any attachments is true and correct False statements included in this application can result in licensure denial
SIGNATURE_____________________________________________________________________ DATE___________ _____________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your Social Security Number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [(42 USCA (c ) (2) (C))] authorizes collection of your Social Security Number Your Social Security Number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your Social Security Number your application for initial license will not be processed and you will be reported to the Franchise Tax Board which may assess a $100 penalty against you
55A-1 (0312)
____
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
RECORD OF NURSING PROGRAM The applicant should complete the first section of this form and provide it to the Director of the nursing program The Director of the nursing program should complete the information in the second section and return it to the above address
THIS SECTION TO BE COMPLETED BY APPLICANT (ITEMS 1-6) PRINT OR TYPE (DO NOT USE PENCIL) 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (MonthDayYear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBERS BUSINESS ( )_________________________________ HOME ( )_________________________________
AREA CODE
THIS SECTION TO BE COMPLETED BY SCHOOLS OF VOCATIONAL PRACTICAL OR REGISTERED NURSING PRINT OR TYPE (DO NOT USE PENCIL)
7 NAME OF SCHOOL OF VOCATIONAL OR PRACTICAL NURSING CITY STATE
______________________________________________________________________ ______________________________________________________
DATE PROGRAM STARTED______________DATE PROGRAM COMPLETED______________ OR DATE VERIFIED HOURS WERE COMPLETED________________
WAS PROGRAM ldquoACCREDITEDrdquo WHEN HOURS WERE COMPLETED YES NO
8 NAME OF SCHOOL OF REGISTERED NURSING CITY STATE
_______________________________________________________________________ _______________________________________________________
DATE PROGRAM STARTED_____________ DATE PROGRAM COMPLETED_______________ OR DATE VERIFIED HOURS WERE COMPLETED________________
WAS PROGRAM ldquoACCREDITEDrdquo WHEN HOURS WERE COMPLETED YES NO
9 COMPLETION OF THE TW ELFTH (12TH) GRADE IN HIGH SCHOOL OR ITS EQUIVALENT HAS BEEN PROVEN BY THE APPLICANT AS FOLLOW S
PRESENTED OFFICIAL SCHOOL RECORDS SHOWING COMPLETION OF 12TH GRADE HIGH SCHOOL
PASSED THE ldquoGEDrdquo TEST AT THE 12TH GRADE LEVEL
10 A TOTAL NUMBER OF THEORYCLINICAL HOURS COMPLETED IN YOUR NURSING PROGRAM
THEORY__________HOURS CLINICAL__________HOURS
B TOTAL NUMBER OF THEORYCLINICAL HOURS WHICH YOUR SCHOOL GRANTED CREDIT FOR ldquoPREVIOUS EDUCATIONrdquo
THEORY__________HOURS CLINICAL__________HOURS
C COMPLETE THE SECOND PAGE OF THIS FORM IN FULL THIS IS A MANDATORY REQUIREMENT
11 I CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
SIGNATURE OF PROGRAM DIRECTOR_____________________________________________
(SCHOOL SEAL) PRINT PROGRAM DIRECTORrsquoS NAME_____________________________________________
DATE________________________________________________________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your social security number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [(42 USCA (c)(2)(C))] authorizes collection of your social security number Your social security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your social security number your application for initial license will not be processed and you will be reported to the Franchise Tax Board
55A-2 (208)
RECORD OF NURSING PROGRAM THIS SECTION OF THE FORM MUST BE COMPLETED IN FULL
1 NAME OF SCHOOL OF NURSING
___________________________________________________________
CHECK ONE
VOCATIONALPRACTICAL NURSING PROGRAM
REGISTERED NURSING PROGRAM
2 CITY 3 STATE AND COUNTRY
4 DATE PROGRAM STARTED ____________________________________
(MONTHDAYYEAR)
5 DATE VERIFIED HOURS WERE COMPLETED____________________________
(MONTHDAYYEAR)
6 SUBJECT ACTUAL HOURSUNITS COMPLETED CHECK HERE
IF SUBJECT IS
INTEGRATED
GRADE RECEIVED HOURSUNITS OF CREDIT GRANTED FOR PREVIOUS
LEARNING
THEORY CLINICAL THEORY CLINICAL THEORY CLINICAL
ANATOMY amp PHYSIOLOGY NA NA NA
NUTRITION NA NA NA
PHARMACOLOGY NA NA NA
PSYCHOLOGY NA NA NA
NORMAL GROWTH amp DEVELOPMENT
NA NA NA
NURSING FUNDAMENTALS
NURSING PROCESS
MEDICAL SURGICAL NURSING
COMMUNICABLE DISEASES
MATERNITY NURSING
PEDIATRIC NURSING
GERONTOLOGICAL NURSING
REHABILITATION NURSING
LEADERSHIP NA NA NA
SUPERVISION NA NA NA
COMMUNICATION NA NA NA
PATIENT EDUCATION NA NA NA
ETHICS amp UNETHICAL CONDUCT NA NA NA
CRITICAL THINKING NA NA NA
CULTURALLY CONGRUENT CARE
END OF LIFE CARE
TOTAL HOURS
____
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
RECORD OF NURSING EXPERIENCE PRINT OR TYPE (DO NOT USE PENCIL)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (monthdayyear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBERS BUSINESS ( )_________________________________ HOME ( )_________________________________
AREA CODE
EXPERIENCE List all nursing experience for the past ten (10) years for which you will be submitting verification of employment It is your responsibility to contact each employer and provide them with a copy of the Employment Verification ndash Nursing Experience Form for completion
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
_________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7B Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From _________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From _________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
NOTE IF MORE SPACE IS NEEDED PLEASE COMPLETE THE SECOND PAGE OF THIS FORM PLEASE READ CAREFULLY BEFORE SIGNING ndash I hereby certify under penalty of perjury under the laws of the State of California that the information
herein including any attachments is true and correct False statements included in this application can result in licensure denial
SIGNATURE_____________________________________________________________________ DATE________________________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your social security number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [42 USCA (c)(2)(C)] authorizes collection of your social security number Your social security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your social security number your application for initial license will not be processed and you will be reported to the Franchise Tax Board which may assess a $100 penalty against you
55A-3(408) 1
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
__________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7E Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7F Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7G Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7H Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7I Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
2
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROW N JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
In order to receive credit for nursing experience State law requires that the Board obtain verification of employment and certification from the Registered Nurse (RN) Director or Supervisor that the applicant has demonstrated the required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
INSTRUCTIONS TO APPLICANT
Complete Part I on the second page of this form and provide a copy of both pages to each employer for the past ten (10) years (You may reproduce as many copies of this form as needed)
This form must be completed in full by the RN Director or Supervisor and returned directly to you in the employerrsquos sealed business envelope The UNOPENED sealed envelopes containing the Employment Verification Forms must be submitted to the Board with your Application for Vocational Nurse Licensure
If you already have an application on the file with the Board and are submitting additional experience the employment verification form may be submitted to the Board by the applicant or the employer but must be received in the employerrsquos sealed business envelope
Please be advised that employment verification forms that appear to have been opened or altered will not be accepted The Board conducts random audits to verify the accuracy of the information submitted Discrepancies or false statements included in the application can result in licensure denial
INSTRUCTIONS TO EMPLOYER
The applicant on page two of this form is applying for licensure as a vocational nurse under Section 2873 of the Business and Professions Code In order for the applicant to receive credit for nursing experience State law requires the Board to obtain verification of employment and certification from the RN Director or Supervisor that the applicant has demonstrated required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
Please complete Parts II III and IV on page two of this form and return it to the applicant in a sealed business envelope Indicate on the outside of the envelope ldquoEmployment Verification Enclosed ndash Do Not Openrdquo It is the applicantrsquos responsibility to collect the Employment Verification Form(s) and submit them with the application for licensure
Part II Indicate the name and type of facility where the experience was obtained Part III Provide the specific dates that the applicant worked under your supervision in the area of
nursing being verified Additionally indicate if the applicant was employed full time (40 hrswk) or part time and include the number of hours worked in each area The Board MUST receive a breakdown of the number of hours spent in each area in order to evaluate the experience
Part IV Indicate whether the applicant has satisfactorily demonstrated each of the knowledge and skills with safety to the patient The skills listed in Part IV(B) may be demonstrated in classroom lab andor patient care settings
Thank you for your assistance Please feel free to contact the Board at (916) 263-7800 if you have any questions
55A-12 (Rev 1007) 1
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
Part I is to be completed by the applicant and submitted to employers for verification of nursing experience The remainder of this form must be completed by the RN Director or Supervisor and returned to the applicant by the employer in a sealed business envelope FORMS CONTAINING STRIKEOUTS OR CORRECTIONS WILL NOT BE ACCEPTED (See Page 1 for detailed instructions on how to complete this form)
Part I To be completed by the Applicant (print or type - do not use pencil)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 NAME WHILE EMPLOYED AT THIS FACILITY 5 SOCIAL SECURITY NUMBER
NOT required but may assist employer in locating records
6 DAYTIME TELEPHONE NUMBER
( )_________________________________ Area Code
Part II To be completed by the Employer - Indicate the name and type of facility where the experience was obtained
Name of facility where experience was obtained
Type of facility Acute or sub-acute(hospital) Home Health
Convalescent Skilled NursingLong Term Care Outpatient Clinicemergency care Other
Assisted Living
Part III To be completed by the Employer - Include dates and the area of nursing being verified Indicate if employment was full-time (40 hrswk) or part-time and include the total number of hours worked in each area
Areas of Bedside Nursing Experience Employment Period (MonthDateYear) Hours Worked
Per Week Total Hours In Each Area
For Office Use Only
Medical-Surgical Nursing From To Pediatric Nursing From To Maternity Nursing From To Genitourinary Nursing From To Psychiatric Nursing From To Office Nursing From To Long Term CareConvalescent From To Private Duty (in a general acute care facility) From To Other From To
Part IV To be completed by the Employer - Indicate if the applicant has satisfactorily demonstrated the following knowledge and skills with safety to the patient
Knowledge and Skills Demonstrated Knowledge and Skills Demonstrated YES NO YES NO
A Basic Bedside Nursing 1 Ambulation Techniques 9 Intake and Output 2 Bedmaking 10 Personal Hygiene and Comfort Measures 3 Urinary Catheter Care 11 Positioning and Transfer 4 Collection of Specimens 12 Range of Motion 5 Diabetic Testing 13 Skin Care 6 Administration of a Cleansing Enema 14 Vital Signs 7 Feeding Patient 15 Communication Skills Both Verbal and
Written Including Communication With Patients Who Have Psychological Disorders
8 Hot and Cold Applications
B Infection Control Procedures (may be demonstrated in classroom lab andor patient care settings) 1 Asepsis 2 Techniques for strict contact respiratory
enteric tuberculosis drainage universal and immunosuppressed patient isolation
TO BE SIGNED BY THE RN DIRECTOR OR SUPERVISOR I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
Signature ___________________________________________ Print Name___________________________________ Nursing License ___________________Exp Date__________ Telephone Number (_____)_ ____________________ Address _____________________________________________ Todayrsquos Date ________________________________ CityState ___________________________ Zip Code_______
55A-12 (Rev 1007) 2 Date Evaluated ____________ Initials ______
55A-6 (1015) - CONTINUED ON REVERSE -
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS RECORD OF CONVICTION
TYPE OR PRINT (USE BLUE OR BLACK INK ONLY) IF MORE SPACE IS NEEDED TO COMPLETE ANY SECTION PLEASE ATTACH ADDITIONAL SHEETS 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APARTMENT NUMBER)
3 CITY STATE ZIP
4 BIRTHDATE (MMDDYYYY) 6 TELEPHONE NUMBERS
CELL (_______) ________________________________________
HOME (_______) ________________________________________
BUSINESS (_______) ________________________________________
5 SOCIAL SECURITY OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER
7 Pursuant to Business and Professions Code Section 480 (c) any false statements included in this application may result in license denial Please carefully read all information contained on the front and back of this form before signing I declare under penalty of perjury under the laws of the State of California that the information provided herein and attachments is true and correct Signature ____________________________________________________________ Date ____________________________________
8 Are you or have you previously been licensed or certified as a psychiatric technician practical vocational or registered nurse or any other healthcare professional in this or any other state territory or country
Yes No
A
State
License Type
License
Expiration Date
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
B Has your license or certification ever been suspended revoked placed on probation or disciplined If Yes you must explain the basis for the disciplinary action and submit a copy of the disciplinary order
Yes No
C Have you used any other names If Yes list all other names used _______________________________________________________________
Yes No
9 Have you ever been convicted of pled guilty to or pled nolo contendere to ANY offense in the United States or a foreign country If YES you must complete item 12 on the back of this form
This includes every citation infraction misdemeanor andor felony excluding traffic violations under $1000 which do not involve alcohol dangerous drugs or controlled substances Convictions that were adjudicated in the juvenile court or convictions under California Health and Safety Code Sections 11357(b) (c) (d) (e) or Section 11360(b) which are two years or older should NOT be reported Convictions that were later dismissed pursuant to section 12034 12034a or 120341 of the California Penal Code or equivalent non-California law MUST be disclosed If you have obtained a dismissal of your conviction(s) pursuant to Penal Code sections 12034 12034(a) or 120341 please submit a certified copy of the court order dismissing the conviction(s) with your application
Yes No
10 Exclusive of juvenile court adjudications and criminal charges dismissed under section 10003 of the California Penal Code or equivalent non-California laws or convictions two years or older under California Health and Safety Code Sections 11357(b) (c) (d) (e) or section 11360(b) have you had a conviction that was set aside or later expunged from the records of the court If YES you must complete item 12 on the back of this form
Yes No
11 Is any court action pending against you or are you currently awaiting judgment and sentencing following entry of a plea or jury verdict If YES you must complete item 12 on the back of this form
Yes No
Important note You will be permitted to take the licensing examination regardless of any criminal conviction history you disclose However a determination as to whether your license will be granted or denied will not be made until you have passed the examination and the board has received all required conviction documentation
12 If you answered yes to item 9 10 or 11 you must provide all of the information requested below for each offense Department of Motor Vehicles printouts are not accepted in lieu of completing this section If more space is needed to complete this section please attach additional sheets
If you have been convicted of a crime you must submit certified court documents police reports and a detailed explanation in your own words for each offense (Certified courtpolice documents are obtained directly from the courtpolice department with an original stamp of certification Do not send copies as they will not contain an original certification and will not meet the requirement for certified documents If the police report andor court documents are no longer available you must obtain a statement from the police department or court attesting to that fact) Additionally please submit documents regarding your rehabilitation efforts such as
Proof that you complied with the terms of your parole probation restitution or any other court imposed sanctions Evidence of expungement proceedings pursuant to penal code section 12034 12034(a) or 120341 Any other evidence of rehabilitation you wish the board to consider
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
Notice on Collection of Personal Information For Applicants and Licensees
Collection and Use of Personal Information The Board of Vocational Nursing and Psychiatric Technicians (BVNPT) of the Department of Consumer Affairs (DCA) collects the personal information requested on this form as authorized by Business and Professions Code Section 30 (General Provisions) Business and Professions Code Division 2 Chapter 65 Articles 1 amp 2 (Vocational Nursing Practice Act) and Chapter 10 Articles 1 amp 2 (Psychiatric Technicians Law) and California Code of Regulations Title 16 Division 25 Chapter 1 (Vocational Nurses) and Chapter 2 (Psychiatric Technicians) The BVNPT uses this information principally to identify and evaluate applicants for licensure issue and renew licenses and enforce licensing standards set by law and regulation
Mandatory Submission Submission of the requested information is mandatory The BVNPT cannot consider your application for licensure or renewal unless you provide all of the requested information
Access to Personal Information You may review the records maintained by the BVNPT that contain your personal information as permitted by the Information Practices Act See below for contact information
Possible Disclosure of Personal Information The BVNPT makes every effort to protect the personal information you provide The information you provide however may be disclosed in the following circumstances
In response to a Public Records Act request (Government Code Section 6250 and following) as allowed by the Information Practices Act (Civil Code Section 1798 and following)
To another government agency as required or permitted by state or federal law or
In response to a court or administrative order a subpoena or a search warrant
Contact Information For questions about this notice or access to your records you may contact the BVNPT at 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833 (916) 263-7800 or email bvnptdcacagov
55P-1 (42109)
Method 4 ndash Military Applicants
Submit all items listed in Step 1 on the first page of these instructions
Record of Military Service (Form 55A-4) - Complete this form in full
In addition you must submit 1 Copies of military service evaluations showing the dates of service wards assigned and duties
performed for each assignment You must demonstrate that you rendered at least twelve (12) months of active duty bedside patient care
2 Transcripts or ldquoCertificate of Release or Discharge from Active Dutyrdquo (DD214) showing completion of basic course of instruction in nursing required by his or her particular branch of the Armed Forces
3 DD214 or other military document showing that service in the Armed Forces has been under honorable conditions or whose general discharge has been under honorable conditions
Currently Licensed as a PracticalVocational Nurse in Another State
If you are currently licensed as a PracticalVocational Nurse in another US State or territory you have received the wrong application package Please contact the Board at (916) 263-7800 and request an Application for Licensure by Endorsement
IMPORTANT INFORMATION Address Change If you change your address after submitting your application for licensure you must notify the Board in writing immediately but no
later than thirty (30) days from the date of the address change
Application Materials The documents you submit will not be returned to you The Record of Nursing Program must be completed by the Director of your educational program and accompanied by an official certified
transcript These documents must be submitted to the Board with your application in an unopened sealed business envelope from the school
Only official transcripts are acceptable (photocopies are not accepted) Official transcripts must list subjects and hours (theory and clinical) completed and the grades received for each subject area Foreign transcripts must be accompanied by a certified translation if not in English
Employment verification forms must be submitted with your application in an unopened sealed business envelope Employment verification forms that appear to have been opened andor altered will not be accepted
Fees The fees for evaluation of your application and processing your fingerprint cards are non -refundable In addition please be advised
that the fingerprint processing fees are subject to change without notice by the DOJ and FBI All applicants for licensure by examination are required to attach a check or money order made payable to the ldquoBVNPTrdquo with their application Please do not send cash
APPLICATION FOR LICENSURE BY EXAMINATION FEE Application Fee $15000
FINGERPRINT PROCESSING FEES FBI Fingerprint Card Processing Fee $1700 DOJ Fingerprint Card Processing Fee $3200
$4900
RETAKE APPLICATION FOR LICENSURE BY EXAMINATION FEE Application Fee $15000
NCLEXreg REGISTRATION After the Board has determined your eligibility for examination you will be mailed a National Council Licensure Examination (NCLEXreg) Candidate Bulletin which contains the examination registration information You must submit a completed NCLEXreg
Registration form and NCLEXreg Registration Fee to the Data Center each time you apply to take the examination See ldquoNCLEX Registration Processrdquo below for details
NCLEXreg Registration Fee $20000
3
INITIAL LICENSE FEE When all requirements for licensure have been met the Board will advise you of the Initial License Fee to be paid This fee is in addition to the application evaluation fee
Filing DeadlinesProcessing Times Applications are accepted on a year-round basis There are no specific filing deadlines However appointments for testing are made
on a first-come first-serve basis You are encouraged to file your application for examination at least three (3) months prior to your anticipated testing da te to allow
sufficient time for evaluation It takes approximately eight (8) weeks for initial processing You will be notified at that time if additional information is needed to complete the evaluation of your application
Name Change If you change your name please notify the Board in writing and attach a copy of one (1) of the following documents Marriage Certificate Divorce Decree Passport or Driverrsquos License
NCLEXreg Registration Process After the Board has determined your eligibility for examination you will be mailed a National Council Licensure Examination
(NCLEXreg) Candidate Bulletin which contains the examination registration information Eligible candidates must register with the NCLEX Data Center within 180 days (6 months) of this notification
The NCLEXreg Registration procedures are
Registration by Mail a Complete the Registration Application Form b Attach a money order or cashierrsquos check for $20000 made payable to ldquoNCSBNrdquo c Mail the Registration Application Form and fee to the NCLEXreg Data Center
Registration by Telephone a Complete the Registration Application Form b Call the NCLEXreg Data Center Directly using the toll free number on the application form c Provide the operator with all of the information contained on the Registration Application Form d Provide the operator with your VISA or MasterCard credit card number and expiration date The registration fee is $20000
Registration by Internet a For internet registration go to wwwvuecomnclex and follow the instructions provided The registration fee is $20000
Scheduling Your Appointment to Test When NCLEXreg Data Center has processed your registration and verified your eligibility with the Board the NCLEXreg Data Center will
mail you an ldquoAuthorization to Testrdquo along with a list of Testing Centers
Select the Testing Center most convenient for you Call that Testing Center and schedule your appointment to take the test
The Testing Center is required to ensure that all eligible first-time applicants are scheduled within thirty (30) days of their requested test date In addition all eligible repeat applicants will be scheduled within forty-five (45) days of their requested test date
Special Accommodations for Disabled Candidates Special testing accommodations are available for candidates with disabilities Disabled candidates must notify the Board prior to
scheduling an appointment to test to obtain the requirements for requesting special accommodations
Disclosure of your Social Security Number is mandatory Section 30 of the Business and Professions Code and Public Law 94shy455 [(42 USCA (c) (2) (C))] authorize collection of your Social Security Number Your Social Security Number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your Social Security Number your application for initial license will not be processed and you will be reported to the Franchise Tax Board
The DOJ currently requires live scan fingerprint services for California residents Applicants submitting live scan fingerprints will be required to pay the fingerprint processing fees at the live scan station All applicants residing out-of-state must submit hard card fingerprints If you reside outside of California and will be submitting the hard card fingerprints rather than live scan fingerprints you must include the $4900 fingerprint processing fees with your fingerprint cards The fingerprint processing fees may be combined with the application fee and submitted to the Board on one check or money order made payable to the BVNPT (see Important Fingerprint Information enclosed)
Retake applicants are not required to submit fingerprint cards and the applicable processing fees unless they have not previously satisfied this requirement or the original application was abandoned Applicants are only required to submit fingerprints and associated processing fees one time
4
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
SUMMARY OF REQUIREMENTS FOR LICENSURE AS A VOCATIONAL NURSE
ALL APPLICANTS FOR LICENSURE AS A VOCATIONAL NURSE IN CALIFORNIA MUST MEET ALL OF THE REQUIREMENTS UNDER SECTION A AND ONE OF THE FOUR METHODS OF QUALIFYING FOR EXAMINATION IN SECTION B
SECTION A
1 BE AT LEAST 17 YEARS OF AGE
2 FURNISH PROOF OF COMPLETION OF THE 12TH GRADE OF SCHOOLING OR ITS EQUIVALENT
3 COMPLETE AND SIGN THE ldquoAPPLICATION FOR VOCATIONAL NURSE LICENSURErdquo AND FURNISH A VALID US SOCIAL SECURITY NUMBER
4 COMPLETE AND SIGN THE ldquoRECORD OF CONVICTIONrdquo FORM
5 NOT BE SUBJECT TO DENIAL PURSUANT TO BUSINESS amp PROFESSIONS CODE SECTION 480
6 SUBMIT THE REQUIRED DEPARTMENT OF JUSTICE (DOJ) AND FEDERAL BUREAU OF INVESTIGATION (FBI) FINGERPRINTS (SEE ENCLOSED ldquoIMPORTANT FINGERPRINT INFORMATIONrdquo) NOTE A LICENSE WILL NOT BE ISSUED UNTIL THE BOARD RECEIVES THE BACKGROUND INFORMATION FROM DOJ
7 ATTACH THE APPROPRIATE NONREFUNDABLE FEE MADE PAYABLE TO THE ldquoBVNPTrdquo (SEE PAGE 3 OF ENCLOSED ldquoINSTRUCTIONS TO APPLICANTS FOR LICENSURE AS A LICENSED VOCATIONAL NURSE)
8 SUCCESSFULLY COMPLETE A WRITTEN EXAMINATION TITLED ldquoNATIONAL COUNCIL LICENSING EXAMINATION FOR PRACTICAL (VOCATIONAL) NURSING (NCLEX PN)rdquo OR THE ldquoNATIONAL LEAGUE FOR NURSING TEST POOL PRACTICAL NURSING EXAMINATION (NLN)rdquo A PASSING SCORE ON A REGISTERED NURSE EXAMINATION WILL NOT SATISFY THIS REQUIREMENT
9 SUBMIT THE INITIAL LICENSE FEE WHEN YOU QUALIFY FOR LICENSURE THE BOARD WILL ADVISE YOU OF THE INITIAL LICENSE FEE TO BE PAID THIS FEE IS IN ADDITION TO THE APPLICATION FEE IT TAKES 4-6 WEEKS TO PROCESS YOUR LICENSE ONCE THIS FEE HAS BEEN RECEIVED
SECTION B - TO BE DEEMED ELIGIBLE FOR EXAMINATION YOU MUST QUALIFY BY ONE OF THE FOLLOWING METHODS
1 GRADUATE OF A CALIFORNIA ACCREDITED SCHOOL OF VOCATIONAL NURSING
YOU MUST HAVE SUCCESSFULLY COMPLETED A CALIFORNIA ACCREDITED VOCATIONAL NURSING PROGRAM
2 GRADUATE OF AN OUT-OF-STATE SCHOOL OF PRACTICALVOCATIONAL NURSING
THE SCHOOL OF PRACTICALVOCATIONAL NURSING FROM WHICH YOU GRADUATED MUST HAVE BEEN ACCREDITED BY THE BOARD OF NURSING IN THE STATE IN WHICH IT IS LOCATED AND THE COURSE CONTENT MUST HAVE BEEN SUBSTANTIALLY EQUIVALENT TO CALIFORNIA CURRICULUM REQUIREMENTS
LICENSURE IN ANOTHER STATE DOES NOT ENTITLE YOU TO PRACTICE AS A LICENSED VOCATIONAL NURSE IN CALIFORNIA IN ORDER TO PRACTICE AS A LICENSED VOCATIONAL NURSE IN CALIFORNIAYOU MUST BE LICENSED BY THE CALIFORNIA STATE BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS
55A-9 (108)
3 EQUIVALENT EDUCATION ANDOR EXPERIENCE
THIS METHOD REQUIRES YOU TO COMPLETE WITHIN TEN (10) YEARS PRIOR TO THE DATE OF APPLICATION NOT LESS THAN FIFTY-ONE (51) MONTHS OF PAID GENERAL DUTY INPATIENT BEDSIDE NURSING EXPERIENCE IN A CLINICAL FACILITY AT LEAST HALF OF WHICH SHALL HAVE BEEN WITHIN FIVE (5) YEARS PRIOR TO THE DATE OF APPLICATION PAID GENERAL DUTY INPATIENT BEDSIDE NURSING EXPERIENCE IS THE PERFORMANCE OF DIRECT PATIENT CARE FUNCTIONS PROVIDED THROUGHOUT THE PATIENTrsquoS STAY THAT ENCOMPASS THE BREADTH AND DEPTH OF EXPERIENCE EQUIVALENT TO THAT PERFORMED BY THE LICENSED VOCATIONAL NURSE YOU MUST ALSO COMPLETE A PHARMACOLOGY COURSE OF AT LEAST 54 THEORY HOURS
A THE PHARMACOLOGY COURSE (54 THEORY HOURS) SHALL INCLUDE BUT IS NOT LIMITED TO KNOWLEDGE OF COMMONLY USED DRUGS AND THEIR ACTION COMPUTATION OF DOSAGES PREPARATION OF MEDICATIONS PRINCIPLES OF ADMINISTRATION
B THE 51 MONTHS OF EXPERIENCE SHALL INCLUDE A MINIMUM OF EACH OF THE FOLLOWING 48 MONTHS MEDICALSURGICAL NURSING 6 WEEKS MATERNITY OR GENITOURINARY NURSING 6 WEEKS PEDIATRIC NURSING
C EXPERIENCE IN ANY OF THE FOLLOWING AREAS MAY BE SUBSTITUTED FOR A MAXIMUM OF EIGHT (8) MONTHS OF MEDICALSURGICAL EXPERIENCE
COMMUNICABLE DISEASE NURSING PRIVATE DUTY NURSING (IN AN ACUTE CARE FACILITY ONLY) PUBLIC HEALTH NURSING EMERGENCY ROOM NURSING OCCUPATIONAL HEALTH NURSING OUT PATIENT CLINIC OFFICE NURSING (MD) POST ANESTHESIA RECOVERY NURSING PSYCHIATRIC NURSING HEMODIALYSIS NURSING OPERATING ROOM NURSING REHABILITATION NURSING GERONTOLOGICAL NURSING EMERGENCY MEDICAL TECHNICIAN SERVICE
D EXPERIENCE MUST BE VERIFIED BY THE EMPLOYER SHOWING SPECIFIC DATES OF EMPLOYMENT AND SHALL INCLUDE CERTIFICATION FROM THE RN DIRECTOR OR SUPERVISOR THAT THE APPLICANT HAS SATISFACTORILY DEMONSTRATED THE FOLLOWING KNOWLEDGE AND SKILLS
1 BASIC BEDSIDE NURSING AMBULATION TECHNIQUES INTAKE AND OUTPUT BEDMAKING PERSONAL HYGIENE AND COMFORT MEASURES URINARY CATHETER CARE POSITIONING AND TRANSFER COLLECTION OF SPECIMENS RANGE OF MOTION DIABETIC TESTING SKIN CARE ADMINISTRATION OF A CLEANSING ENEMA VITAL SIGNS FEEDING PATIENT HOT AND COLD APPLICATIONS COMMUNICATION SKILLS BOTH VERBAL AND WRITTEN INCLUDING
COMMUNICATION WITH PATIENTS WHO HAVE PSYCHOLOGICAL DISORDERS
2 INFECTION CONTROL PROCEDURES (MAY BE DEMONSTRATED IN CLASSROOM LAB ANDOR PATIENT CARE SETTINGS)
ASEPSIS TECHNIQUES FOR STRICT CONTACT RESPIRATORY ENTERIC TUBERCULOSIS DRAINAGE UNIVERSAL AND
IMMUNOSUPPRESSED PATIENT ISOLATION
APPLICANTS WITH FORMAL NURSING EDUCATION MAY SUBMIT OFFICIAL TRANSCRIPTS FOR EVALUATION FOR POSSIBLE CREDIT IN LIEU OF PAID BEDSIDE NURSING EXPERIENCE THE TRANSCRIPTS MUST BE SUBMITTED TO THE BOARD DIRECTLY FROM THE SCHOOL AND MUST SHOW THEORY AND CLINICAL HOURS COMPLETED
4 NURSING SERVICE IN THE MEDICAL CORPS OF ANY BRANCH OF THE ARMED FORCES OF THE UNITED STATES THIS METHOD REQUIRES
A MILITARY SERVICE EVALUATIONS SHOWING AT LEAST TWELVE (12) MONTHS SERVICE ON ACTIVE DUTY IN THE MEDICAL CORPS OF ANY OF THE ARMED FORCES RENDERING BEDSIDE PATIENT CARE MILITARY SERVICE EVALUATIONS MUST BE SUBMITTED SHOWING THE DATES OF SERVICE WARDS ASSIGNED AND THE DUTIES PERFORMED FOR EACH ASSIGNMENT
B TRANSCRIPTS OR ldquoCERTIFICATE OF RELEASE OR DISCHARGE FROM ACTIVE DUTYrdquo (DD 214) SHOWING COMPLETION OF BASIC COURSE OF INSTRUCTION IN NURSING REQUIRED BY HIS OR HER PARTICULAR BRANCH OF THE ARMED FORCES
C DD 214 OR OTHER MILITARY DOCUMENT SHOWING THAT SERVICE IN THE ARMED FORCES HAS BEEN UNDER HONORABLE CONDITIONS OR WHOSE GENERAL DISCHARGE HAS BEEN UNDER HONORABLE CONDITIONS
NOTE A COMBINATION OF MILITARY AND NONMILITARY EXPERIENCE IS NOT ACCEPTABLE UNDER THIS METHOD PROOF OF 12TH
GRADE EDUCATION IS NOT REQUIRED UNDER THIS METHOD
NOTE STATE BOARDS OF NURSING IN MANY STATES REQUIRE GRADUATION FROM AN ACCREDITED SCHOOL OF NURSING PLEASE BE AWARE THAT APPLICANTS DEEMED ELIGIBLE FOR LICENSURE IN CALIFORNIA USING OTHER METHODS OF QUALIFYING (IE MILITARY EXPERIENCE OR EQUIVALENT EDUCATION AND EXPERIENCE) MAY NOT BE ELIGIBLE FOR LICENSURE BY ENDORSEMENT IN OTHER STATES
2
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
APPLICATION FOR VOCATIONAL NURSE LICENSURE
(ATTACH $150 APPLICATION FEE AN ADDITIONAL $49 FINGERPRINT FEE IS REQUIRED FOR PROCESSING ldquoHARD CARDrdquo FINGERPRINTS ndash SEE ENCLOSED INSTRUCTIONS )
Read all the enclosed instructions carefully before completing this application This information is required under Business and Professions Code Division 2 Chapter 65 Articles 1 and 2 The information you furnish will be used to determine your eligibility for licensure If additional space is needed to complete any section of this application please attach additional sheets The Executive Officer of the Board is responsible for information maintenance
PRINT OR TYPE (DO NOT USE PENCIL)
DO NOT WRITE IN THIS SPACE
APP NO
LIC NO
ILF-CA NO
ATS NO
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (MonthDayYear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBER Business (____)_________________________ Home (_____)_________________________
Area Code
7 DID YOU GRADUATE FROM HIGH SCHOOL YES NO NAME OF HIGH SCHOOL_______________________________ CITYSTATE_________________
DID YOU PASS A HIGH SCHOOL EQUIVALENCY TEST YES NO IF NO CIRCLE THE HIGHEST GRADE YOUCOMPLETED 1 2 3 4 5 6 7 8 9 10 11 12
8 DID YOU ATTEND A VOCATIONALPRACTICAL NURSING PROGRAM YES NO DID YOU GRADUATE FROM THE PROGRAM YES NO IF YES NAME OF VOCATIONALPRACTICAL NURSING PROGRAM DATE STARTED DATE COMPLETED STATE OR COUNTRY
_________________________________________________________ ________________ __________________ ___________________
9 DID YOU ATTEND A REGISTERED NURSING PROGRAM YES NO DID YOU GRADUATE FROM THE PROGRAM YES NO IF YES NAME OF REGISTERED NURSING PROGRAM DATE STARTED DATE COMPLETED STATE OR COUNTRY
_________________________________________________________ ________________ __________________ ________________
10 HAVE YOU EVER BEEN LICENSED AS A VOCATIONALPRACTICAL NURSE YES NO DATE LICENSED___________ STATE OF ORIGINAL LICENSE______
IF YES HAS THIS LICENSE EVER BEEN SUSPENDED REVOKED OR PLACED ON PROBATION YES NO (IF YES ATTACH EXPLANATION)
11 HAVE YOU EVER BEEN LICENSED AS A REGISTERED NURSE YES NO DATE LICENSED____________STATE OF ORIGINAL LICENSE____________
IF YES HAS THIS LICENSE EVER BEEN SUSPENDED REVOKED OR PLACED ON PROBATION YES NO (IF YES ATTACH EXPLANATION)
12 HAVE YOU EVER APPLIED TO THIS BOARD FOR LICENSURE UNDER A DIFFERENT NAME YES NO IF ldquoYESrdquo PLEASE LIST OTHER NAMES
WILL DOCUMENTS BE SUBMITTED TO THIS BOARD UNDER A DIFFERENT NAME YES NO IF YES PLEASE LIST OTHER NAMES
13 CONFIDENTIALITY NOTICE YOU ARE ADVISED THAT PURSUANT TO BUSINESS AND PROFESSIONS CODE SECTION 123 THE CONTENT OF THE VOCATIONAL NURSE LICENSURE EXAMINATION IS CONFIDENTIAL IF YOU ARE DEEMED ELIGIBLE TO TAKE THIS EXAMINATION YOU ARE HEREBY NOTIFIED THAT UNAUTHORIZED POSSESSION REPRODUCTION OR DISCLOSURE OF ANY EXAMINATION MATERIALS IS IN VIOLATION OF THE LAW AND SUBJECT TO CRIMINAL MISDEMEANOR PROSECUTION A VIOLAT ION OF THIS TYPE MAY ALSO RESULT IN CIVIL LIABILITY ANDOR DISCIPLINE BY THE LICENSING AGENCY INCLUDING THE DENIAL OF LICENSURE
14 PHOTOGRAPH REQUIREMENTS YOU MUST ATTACH A CURRENT FRONT VIEW HEAD AND SHOULDER PHOTOGRAPH OF YOURSELF IN A SEALED ENVELOPE THE PHOTOGRAPH SHOULD BE 2rdquo X 2rdquo AND MUST BE SIGNED ON THE BACK
15 PLEASE READ CAREFULLY BEFORE SIGNING ndash I hereby certify under penalty of perjury under the laws of the State of California that
the foregoing including any attachments is true and correct False statements included in this application can result in licensure denial
SIGNATURE_____________________________________________________________________ DATE___________ _____________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your Social Security Number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [(42 USCA (c ) (2) (C))] authorizes collection of your Social Security Number Your Social Security Number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your Social Security Number your application for initial license will not be processed and you will be reported to the Franchise Tax Board which may assess a $100 penalty against you
55A-1 (0312)
____
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
RECORD OF NURSING PROGRAM The applicant should complete the first section of this form and provide it to the Director of the nursing program The Director of the nursing program should complete the information in the second section and return it to the above address
THIS SECTION TO BE COMPLETED BY APPLICANT (ITEMS 1-6) PRINT OR TYPE (DO NOT USE PENCIL) 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (MonthDayYear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBERS BUSINESS ( )_________________________________ HOME ( )_________________________________
AREA CODE
THIS SECTION TO BE COMPLETED BY SCHOOLS OF VOCATIONAL PRACTICAL OR REGISTERED NURSING PRINT OR TYPE (DO NOT USE PENCIL)
7 NAME OF SCHOOL OF VOCATIONAL OR PRACTICAL NURSING CITY STATE
______________________________________________________________________ ______________________________________________________
DATE PROGRAM STARTED______________DATE PROGRAM COMPLETED______________ OR DATE VERIFIED HOURS WERE COMPLETED________________
WAS PROGRAM ldquoACCREDITEDrdquo WHEN HOURS WERE COMPLETED YES NO
8 NAME OF SCHOOL OF REGISTERED NURSING CITY STATE
_______________________________________________________________________ _______________________________________________________
DATE PROGRAM STARTED_____________ DATE PROGRAM COMPLETED_______________ OR DATE VERIFIED HOURS WERE COMPLETED________________
WAS PROGRAM ldquoACCREDITEDrdquo WHEN HOURS WERE COMPLETED YES NO
9 COMPLETION OF THE TW ELFTH (12TH) GRADE IN HIGH SCHOOL OR ITS EQUIVALENT HAS BEEN PROVEN BY THE APPLICANT AS FOLLOW S
PRESENTED OFFICIAL SCHOOL RECORDS SHOWING COMPLETION OF 12TH GRADE HIGH SCHOOL
PASSED THE ldquoGEDrdquo TEST AT THE 12TH GRADE LEVEL
10 A TOTAL NUMBER OF THEORYCLINICAL HOURS COMPLETED IN YOUR NURSING PROGRAM
THEORY__________HOURS CLINICAL__________HOURS
B TOTAL NUMBER OF THEORYCLINICAL HOURS WHICH YOUR SCHOOL GRANTED CREDIT FOR ldquoPREVIOUS EDUCATIONrdquo
THEORY__________HOURS CLINICAL__________HOURS
C COMPLETE THE SECOND PAGE OF THIS FORM IN FULL THIS IS A MANDATORY REQUIREMENT
11 I CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
SIGNATURE OF PROGRAM DIRECTOR_____________________________________________
(SCHOOL SEAL) PRINT PROGRAM DIRECTORrsquoS NAME_____________________________________________
DATE________________________________________________________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your social security number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [(42 USCA (c)(2)(C))] authorizes collection of your social security number Your social security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your social security number your application for initial license will not be processed and you will be reported to the Franchise Tax Board
55A-2 (208)
RECORD OF NURSING PROGRAM THIS SECTION OF THE FORM MUST BE COMPLETED IN FULL
1 NAME OF SCHOOL OF NURSING
___________________________________________________________
CHECK ONE
VOCATIONALPRACTICAL NURSING PROGRAM
REGISTERED NURSING PROGRAM
2 CITY 3 STATE AND COUNTRY
4 DATE PROGRAM STARTED ____________________________________
(MONTHDAYYEAR)
5 DATE VERIFIED HOURS WERE COMPLETED____________________________
(MONTHDAYYEAR)
6 SUBJECT ACTUAL HOURSUNITS COMPLETED CHECK HERE
IF SUBJECT IS
INTEGRATED
GRADE RECEIVED HOURSUNITS OF CREDIT GRANTED FOR PREVIOUS
LEARNING
THEORY CLINICAL THEORY CLINICAL THEORY CLINICAL
ANATOMY amp PHYSIOLOGY NA NA NA
NUTRITION NA NA NA
PHARMACOLOGY NA NA NA
PSYCHOLOGY NA NA NA
NORMAL GROWTH amp DEVELOPMENT
NA NA NA
NURSING FUNDAMENTALS
NURSING PROCESS
MEDICAL SURGICAL NURSING
COMMUNICABLE DISEASES
MATERNITY NURSING
PEDIATRIC NURSING
GERONTOLOGICAL NURSING
REHABILITATION NURSING
LEADERSHIP NA NA NA
SUPERVISION NA NA NA
COMMUNICATION NA NA NA
PATIENT EDUCATION NA NA NA
ETHICS amp UNETHICAL CONDUCT NA NA NA
CRITICAL THINKING NA NA NA
CULTURALLY CONGRUENT CARE
END OF LIFE CARE
TOTAL HOURS
____
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
RECORD OF NURSING EXPERIENCE PRINT OR TYPE (DO NOT USE PENCIL)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (monthdayyear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBERS BUSINESS ( )_________________________________ HOME ( )_________________________________
AREA CODE
EXPERIENCE List all nursing experience for the past ten (10) years for which you will be submitting verification of employment It is your responsibility to contact each employer and provide them with a copy of the Employment Verification ndash Nursing Experience Form for completion
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
_________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7B Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From _________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From _________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
NOTE IF MORE SPACE IS NEEDED PLEASE COMPLETE THE SECOND PAGE OF THIS FORM PLEASE READ CAREFULLY BEFORE SIGNING ndash I hereby certify under penalty of perjury under the laws of the State of California that the information
herein including any attachments is true and correct False statements included in this application can result in licensure denial
SIGNATURE_____________________________________________________________________ DATE________________________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your social security number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [42 USCA (c)(2)(C)] authorizes collection of your social security number Your social security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your social security number your application for initial license will not be processed and you will be reported to the Franchise Tax Board which may assess a $100 penalty against you
55A-3(408) 1
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
__________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7E Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7F Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7G Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7H Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7I Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
2
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROW N JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
In order to receive credit for nursing experience State law requires that the Board obtain verification of employment and certification from the Registered Nurse (RN) Director or Supervisor that the applicant has demonstrated the required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
INSTRUCTIONS TO APPLICANT
Complete Part I on the second page of this form and provide a copy of both pages to each employer for the past ten (10) years (You may reproduce as many copies of this form as needed)
This form must be completed in full by the RN Director or Supervisor and returned directly to you in the employerrsquos sealed business envelope The UNOPENED sealed envelopes containing the Employment Verification Forms must be submitted to the Board with your Application for Vocational Nurse Licensure
If you already have an application on the file with the Board and are submitting additional experience the employment verification form may be submitted to the Board by the applicant or the employer but must be received in the employerrsquos sealed business envelope
Please be advised that employment verification forms that appear to have been opened or altered will not be accepted The Board conducts random audits to verify the accuracy of the information submitted Discrepancies or false statements included in the application can result in licensure denial
INSTRUCTIONS TO EMPLOYER
The applicant on page two of this form is applying for licensure as a vocational nurse under Section 2873 of the Business and Professions Code In order for the applicant to receive credit for nursing experience State law requires the Board to obtain verification of employment and certification from the RN Director or Supervisor that the applicant has demonstrated required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
Please complete Parts II III and IV on page two of this form and return it to the applicant in a sealed business envelope Indicate on the outside of the envelope ldquoEmployment Verification Enclosed ndash Do Not Openrdquo It is the applicantrsquos responsibility to collect the Employment Verification Form(s) and submit them with the application for licensure
Part II Indicate the name and type of facility where the experience was obtained Part III Provide the specific dates that the applicant worked under your supervision in the area of
nursing being verified Additionally indicate if the applicant was employed full time (40 hrswk) or part time and include the number of hours worked in each area The Board MUST receive a breakdown of the number of hours spent in each area in order to evaluate the experience
Part IV Indicate whether the applicant has satisfactorily demonstrated each of the knowledge and skills with safety to the patient The skills listed in Part IV(B) may be demonstrated in classroom lab andor patient care settings
Thank you for your assistance Please feel free to contact the Board at (916) 263-7800 if you have any questions
55A-12 (Rev 1007) 1
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
Part I is to be completed by the applicant and submitted to employers for verification of nursing experience The remainder of this form must be completed by the RN Director or Supervisor and returned to the applicant by the employer in a sealed business envelope FORMS CONTAINING STRIKEOUTS OR CORRECTIONS WILL NOT BE ACCEPTED (See Page 1 for detailed instructions on how to complete this form)
Part I To be completed by the Applicant (print or type - do not use pencil)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 NAME WHILE EMPLOYED AT THIS FACILITY 5 SOCIAL SECURITY NUMBER
NOT required but may assist employer in locating records
6 DAYTIME TELEPHONE NUMBER
( )_________________________________ Area Code
Part II To be completed by the Employer - Indicate the name and type of facility where the experience was obtained
Name of facility where experience was obtained
Type of facility Acute or sub-acute(hospital) Home Health
Convalescent Skilled NursingLong Term Care Outpatient Clinicemergency care Other
Assisted Living
Part III To be completed by the Employer - Include dates and the area of nursing being verified Indicate if employment was full-time (40 hrswk) or part-time and include the total number of hours worked in each area
Areas of Bedside Nursing Experience Employment Period (MonthDateYear) Hours Worked
Per Week Total Hours In Each Area
For Office Use Only
Medical-Surgical Nursing From To Pediatric Nursing From To Maternity Nursing From To Genitourinary Nursing From To Psychiatric Nursing From To Office Nursing From To Long Term CareConvalescent From To Private Duty (in a general acute care facility) From To Other From To
Part IV To be completed by the Employer - Indicate if the applicant has satisfactorily demonstrated the following knowledge and skills with safety to the patient
Knowledge and Skills Demonstrated Knowledge and Skills Demonstrated YES NO YES NO
A Basic Bedside Nursing 1 Ambulation Techniques 9 Intake and Output 2 Bedmaking 10 Personal Hygiene and Comfort Measures 3 Urinary Catheter Care 11 Positioning and Transfer 4 Collection of Specimens 12 Range of Motion 5 Diabetic Testing 13 Skin Care 6 Administration of a Cleansing Enema 14 Vital Signs 7 Feeding Patient 15 Communication Skills Both Verbal and
Written Including Communication With Patients Who Have Psychological Disorders
8 Hot and Cold Applications
B Infection Control Procedures (may be demonstrated in classroom lab andor patient care settings) 1 Asepsis 2 Techniques for strict contact respiratory
enteric tuberculosis drainage universal and immunosuppressed patient isolation
TO BE SIGNED BY THE RN DIRECTOR OR SUPERVISOR I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
Signature ___________________________________________ Print Name___________________________________ Nursing License ___________________Exp Date__________ Telephone Number (_____)_ ____________________ Address _____________________________________________ Todayrsquos Date ________________________________ CityState ___________________________ Zip Code_______
55A-12 (Rev 1007) 2 Date Evaluated ____________ Initials ______
55A-6 (1015) - CONTINUED ON REVERSE -
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS RECORD OF CONVICTION
TYPE OR PRINT (USE BLUE OR BLACK INK ONLY) IF MORE SPACE IS NEEDED TO COMPLETE ANY SECTION PLEASE ATTACH ADDITIONAL SHEETS 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APARTMENT NUMBER)
3 CITY STATE ZIP
4 BIRTHDATE (MMDDYYYY) 6 TELEPHONE NUMBERS
CELL (_______) ________________________________________
HOME (_______) ________________________________________
BUSINESS (_______) ________________________________________
5 SOCIAL SECURITY OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER
7 Pursuant to Business and Professions Code Section 480 (c) any false statements included in this application may result in license denial Please carefully read all information contained on the front and back of this form before signing I declare under penalty of perjury under the laws of the State of California that the information provided herein and attachments is true and correct Signature ____________________________________________________________ Date ____________________________________
8 Are you or have you previously been licensed or certified as a psychiatric technician practical vocational or registered nurse or any other healthcare professional in this or any other state territory or country
Yes No
A
State
License Type
License
Expiration Date
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
B Has your license or certification ever been suspended revoked placed on probation or disciplined If Yes you must explain the basis for the disciplinary action and submit a copy of the disciplinary order
Yes No
C Have you used any other names If Yes list all other names used _______________________________________________________________
Yes No
9 Have you ever been convicted of pled guilty to or pled nolo contendere to ANY offense in the United States or a foreign country If YES you must complete item 12 on the back of this form
This includes every citation infraction misdemeanor andor felony excluding traffic violations under $1000 which do not involve alcohol dangerous drugs or controlled substances Convictions that were adjudicated in the juvenile court or convictions under California Health and Safety Code Sections 11357(b) (c) (d) (e) or Section 11360(b) which are two years or older should NOT be reported Convictions that were later dismissed pursuant to section 12034 12034a or 120341 of the California Penal Code or equivalent non-California law MUST be disclosed If you have obtained a dismissal of your conviction(s) pursuant to Penal Code sections 12034 12034(a) or 120341 please submit a certified copy of the court order dismissing the conviction(s) with your application
Yes No
10 Exclusive of juvenile court adjudications and criminal charges dismissed under section 10003 of the California Penal Code or equivalent non-California laws or convictions two years or older under California Health and Safety Code Sections 11357(b) (c) (d) (e) or section 11360(b) have you had a conviction that was set aside or later expunged from the records of the court If YES you must complete item 12 on the back of this form
Yes No
11 Is any court action pending against you or are you currently awaiting judgment and sentencing following entry of a plea or jury verdict If YES you must complete item 12 on the back of this form
Yes No
Important note You will be permitted to take the licensing examination regardless of any criminal conviction history you disclose However a determination as to whether your license will be granted or denied will not be made until you have passed the examination and the board has received all required conviction documentation
12 If you answered yes to item 9 10 or 11 you must provide all of the information requested below for each offense Department of Motor Vehicles printouts are not accepted in lieu of completing this section If more space is needed to complete this section please attach additional sheets
If you have been convicted of a crime you must submit certified court documents police reports and a detailed explanation in your own words for each offense (Certified courtpolice documents are obtained directly from the courtpolice department with an original stamp of certification Do not send copies as they will not contain an original certification and will not meet the requirement for certified documents If the police report andor court documents are no longer available you must obtain a statement from the police department or court attesting to that fact) Additionally please submit documents regarding your rehabilitation efforts such as
Proof that you complied with the terms of your parole probation restitution or any other court imposed sanctions Evidence of expungement proceedings pursuant to penal code section 12034 12034(a) or 120341 Any other evidence of rehabilitation you wish the board to consider
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
Notice on Collection of Personal Information For Applicants and Licensees
Collection and Use of Personal Information The Board of Vocational Nursing and Psychiatric Technicians (BVNPT) of the Department of Consumer Affairs (DCA) collects the personal information requested on this form as authorized by Business and Professions Code Section 30 (General Provisions) Business and Professions Code Division 2 Chapter 65 Articles 1 amp 2 (Vocational Nursing Practice Act) and Chapter 10 Articles 1 amp 2 (Psychiatric Technicians Law) and California Code of Regulations Title 16 Division 25 Chapter 1 (Vocational Nurses) and Chapter 2 (Psychiatric Technicians) The BVNPT uses this information principally to identify and evaluate applicants for licensure issue and renew licenses and enforce licensing standards set by law and regulation
Mandatory Submission Submission of the requested information is mandatory The BVNPT cannot consider your application for licensure or renewal unless you provide all of the requested information
Access to Personal Information You may review the records maintained by the BVNPT that contain your personal information as permitted by the Information Practices Act See below for contact information
Possible Disclosure of Personal Information The BVNPT makes every effort to protect the personal information you provide The information you provide however may be disclosed in the following circumstances
In response to a Public Records Act request (Government Code Section 6250 and following) as allowed by the Information Practices Act (Civil Code Section 1798 and following)
To another government agency as required or permitted by state or federal law or
In response to a court or administrative order a subpoena or a search warrant
Contact Information For questions about this notice or access to your records you may contact the BVNPT at 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833 (916) 263-7800 or email bvnptdcacagov
55P-1 (42109)
INITIAL LICENSE FEE When all requirements for licensure have been met the Board will advise you of the Initial License Fee to be paid This fee is in addition to the application evaluation fee
Filing DeadlinesProcessing Times Applications are accepted on a year-round basis There are no specific filing deadlines However appointments for testing are made
on a first-come first-serve basis You are encouraged to file your application for examination at least three (3) months prior to your anticipated testing da te to allow
sufficient time for evaluation It takes approximately eight (8) weeks for initial processing You will be notified at that time if additional information is needed to complete the evaluation of your application
Name Change If you change your name please notify the Board in writing and attach a copy of one (1) of the following documents Marriage Certificate Divorce Decree Passport or Driverrsquos License
NCLEXreg Registration Process After the Board has determined your eligibility for examination you will be mailed a National Council Licensure Examination
(NCLEXreg) Candidate Bulletin which contains the examination registration information Eligible candidates must register with the NCLEX Data Center within 180 days (6 months) of this notification
The NCLEXreg Registration procedures are
Registration by Mail a Complete the Registration Application Form b Attach a money order or cashierrsquos check for $20000 made payable to ldquoNCSBNrdquo c Mail the Registration Application Form and fee to the NCLEXreg Data Center
Registration by Telephone a Complete the Registration Application Form b Call the NCLEXreg Data Center Directly using the toll free number on the application form c Provide the operator with all of the information contained on the Registration Application Form d Provide the operator with your VISA or MasterCard credit card number and expiration date The registration fee is $20000
Registration by Internet a For internet registration go to wwwvuecomnclex and follow the instructions provided The registration fee is $20000
Scheduling Your Appointment to Test When NCLEXreg Data Center has processed your registration and verified your eligibility with the Board the NCLEXreg Data Center will
mail you an ldquoAuthorization to Testrdquo along with a list of Testing Centers
Select the Testing Center most convenient for you Call that Testing Center and schedule your appointment to take the test
The Testing Center is required to ensure that all eligible first-time applicants are scheduled within thirty (30) days of their requested test date In addition all eligible repeat applicants will be scheduled within forty-five (45) days of their requested test date
Special Accommodations for Disabled Candidates Special testing accommodations are available for candidates with disabilities Disabled candidates must notify the Board prior to
scheduling an appointment to test to obtain the requirements for requesting special accommodations
Disclosure of your Social Security Number is mandatory Section 30 of the Business and Professions Code and Public Law 94shy455 [(42 USCA (c) (2) (C))] authorize collection of your Social Security Number Your Social Security Number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your Social Security Number your application for initial license will not be processed and you will be reported to the Franchise Tax Board
The DOJ currently requires live scan fingerprint services for California residents Applicants submitting live scan fingerprints will be required to pay the fingerprint processing fees at the live scan station All applicants residing out-of-state must submit hard card fingerprints If you reside outside of California and will be submitting the hard card fingerprints rather than live scan fingerprints you must include the $4900 fingerprint processing fees with your fingerprint cards The fingerprint processing fees may be combined with the application fee and submitted to the Board on one check or money order made payable to the BVNPT (see Important Fingerprint Information enclosed)
Retake applicants are not required to submit fingerprint cards and the applicable processing fees unless they have not previously satisfied this requirement or the original application was abandoned Applicants are only required to submit fingerprints and associated processing fees one time
4
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
SUMMARY OF REQUIREMENTS FOR LICENSURE AS A VOCATIONAL NURSE
ALL APPLICANTS FOR LICENSURE AS A VOCATIONAL NURSE IN CALIFORNIA MUST MEET ALL OF THE REQUIREMENTS UNDER SECTION A AND ONE OF THE FOUR METHODS OF QUALIFYING FOR EXAMINATION IN SECTION B
SECTION A
1 BE AT LEAST 17 YEARS OF AGE
2 FURNISH PROOF OF COMPLETION OF THE 12TH GRADE OF SCHOOLING OR ITS EQUIVALENT
3 COMPLETE AND SIGN THE ldquoAPPLICATION FOR VOCATIONAL NURSE LICENSURErdquo AND FURNISH A VALID US SOCIAL SECURITY NUMBER
4 COMPLETE AND SIGN THE ldquoRECORD OF CONVICTIONrdquo FORM
5 NOT BE SUBJECT TO DENIAL PURSUANT TO BUSINESS amp PROFESSIONS CODE SECTION 480
6 SUBMIT THE REQUIRED DEPARTMENT OF JUSTICE (DOJ) AND FEDERAL BUREAU OF INVESTIGATION (FBI) FINGERPRINTS (SEE ENCLOSED ldquoIMPORTANT FINGERPRINT INFORMATIONrdquo) NOTE A LICENSE WILL NOT BE ISSUED UNTIL THE BOARD RECEIVES THE BACKGROUND INFORMATION FROM DOJ
7 ATTACH THE APPROPRIATE NONREFUNDABLE FEE MADE PAYABLE TO THE ldquoBVNPTrdquo (SEE PAGE 3 OF ENCLOSED ldquoINSTRUCTIONS TO APPLICANTS FOR LICENSURE AS A LICENSED VOCATIONAL NURSE)
8 SUCCESSFULLY COMPLETE A WRITTEN EXAMINATION TITLED ldquoNATIONAL COUNCIL LICENSING EXAMINATION FOR PRACTICAL (VOCATIONAL) NURSING (NCLEX PN)rdquo OR THE ldquoNATIONAL LEAGUE FOR NURSING TEST POOL PRACTICAL NURSING EXAMINATION (NLN)rdquo A PASSING SCORE ON A REGISTERED NURSE EXAMINATION WILL NOT SATISFY THIS REQUIREMENT
9 SUBMIT THE INITIAL LICENSE FEE WHEN YOU QUALIFY FOR LICENSURE THE BOARD WILL ADVISE YOU OF THE INITIAL LICENSE FEE TO BE PAID THIS FEE IS IN ADDITION TO THE APPLICATION FEE IT TAKES 4-6 WEEKS TO PROCESS YOUR LICENSE ONCE THIS FEE HAS BEEN RECEIVED
SECTION B - TO BE DEEMED ELIGIBLE FOR EXAMINATION YOU MUST QUALIFY BY ONE OF THE FOLLOWING METHODS
1 GRADUATE OF A CALIFORNIA ACCREDITED SCHOOL OF VOCATIONAL NURSING
YOU MUST HAVE SUCCESSFULLY COMPLETED A CALIFORNIA ACCREDITED VOCATIONAL NURSING PROGRAM
2 GRADUATE OF AN OUT-OF-STATE SCHOOL OF PRACTICALVOCATIONAL NURSING
THE SCHOOL OF PRACTICALVOCATIONAL NURSING FROM WHICH YOU GRADUATED MUST HAVE BEEN ACCREDITED BY THE BOARD OF NURSING IN THE STATE IN WHICH IT IS LOCATED AND THE COURSE CONTENT MUST HAVE BEEN SUBSTANTIALLY EQUIVALENT TO CALIFORNIA CURRICULUM REQUIREMENTS
LICENSURE IN ANOTHER STATE DOES NOT ENTITLE YOU TO PRACTICE AS A LICENSED VOCATIONAL NURSE IN CALIFORNIA IN ORDER TO PRACTICE AS A LICENSED VOCATIONAL NURSE IN CALIFORNIAYOU MUST BE LICENSED BY THE CALIFORNIA STATE BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS
55A-9 (108)
3 EQUIVALENT EDUCATION ANDOR EXPERIENCE
THIS METHOD REQUIRES YOU TO COMPLETE WITHIN TEN (10) YEARS PRIOR TO THE DATE OF APPLICATION NOT LESS THAN FIFTY-ONE (51) MONTHS OF PAID GENERAL DUTY INPATIENT BEDSIDE NURSING EXPERIENCE IN A CLINICAL FACILITY AT LEAST HALF OF WHICH SHALL HAVE BEEN WITHIN FIVE (5) YEARS PRIOR TO THE DATE OF APPLICATION PAID GENERAL DUTY INPATIENT BEDSIDE NURSING EXPERIENCE IS THE PERFORMANCE OF DIRECT PATIENT CARE FUNCTIONS PROVIDED THROUGHOUT THE PATIENTrsquoS STAY THAT ENCOMPASS THE BREADTH AND DEPTH OF EXPERIENCE EQUIVALENT TO THAT PERFORMED BY THE LICENSED VOCATIONAL NURSE YOU MUST ALSO COMPLETE A PHARMACOLOGY COURSE OF AT LEAST 54 THEORY HOURS
A THE PHARMACOLOGY COURSE (54 THEORY HOURS) SHALL INCLUDE BUT IS NOT LIMITED TO KNOWLEDGE OF COMMONLY USED DRUGS AND THEIR ACTION COMPUTATION OF DOSAGES PREPARATION OF MEDICATIONS PRINCIPLES OF ADMINISTRATION
B THE 51 MONTHS OF EXPERIENCE SHALL INCLUDE A MINIMUM OF EACH OF THE FOLLOWING 48 MONTHS MEDICALSURGICAL NURSING 6 WEEKS MATERNITY OR GENITOURINARY NURSING 6 WEEKS PEDIATRIC NURSING
C EXPERIENCE IN ANY OF THE FOLLOWING AREAS MAY BE SUBSTITUTED FOR A MAXIMUM OF EIGHT (8) MONTHS OF MEDICALSURGICAL EXPERIENCE
COMMUNICABLE DISEASE NURSING PRIVATE DUTY NURSING (IN AN ACUTE CARE FACILITY ONLY) PUBLIC HEALTH NURSING EMERGENCY ROOM NURSING OCCUPATIONAL HEALTH NURSING OUT PATIENT CLINIC OFFICE NURSING (MD) POST ANESTHESIA RECOVERY NURSING PSYCHIATRIC NURSING HEMODIALYSIS NURSING OPERATING ROOM NURSING REHABILITATION NURSING GERONTOLOGICAL NURSING EMERGENCY MEDICAL TECHNICIAN SERVICE
D EXPERIENCE MUST BE VERIFIED BY THE EMPLOYER SHOWING SPECIFIC DATES OF EMPLOYMENT AND SHALL INCLUDE CERTIFICATION FROM THE RN DIRECTOR OR SUPERVISOR THAT THE APPLICANT HAS SATISFACTORILY DEMONSTRATED THE FOLLOWING KNOWLEDGE AND SKILLS
1 BASIC BEDSIDE NURSING AMBULATION TECHNIQUES INTAKE AND OUTPUT BEDMAKING PERSONAL HYGIENE AND COMFORT MEASURES URINARY CATHETER CARE POSITIONING AND TRANSFER COLLECTION OF SPECIMENS RANGE OF MOTION DIABETIC TESTING SKIN CARE ADMINISTRATION OF A CLEANSING ENEMA VITAL SIGNS FEEDING PATIENT HOT AND COLD APPLICATIONS COMMUNICATION SKILLS BOTH VERBAL AND WRITTEN INCLUDING
COMMUNICATION WITH PATIENTS WHO HAVE PSYCHOLOGICAL DISORDERS
2 INFECTION CONTROL PROCEDURES (MAY BE DEMONSTRATED IN CLASSROOM LAB ANDOR PATIENT CARE SETTINGS)
ASEPSIS TECHNIQUES FOR STRICT CONTACT RESPIRATORY ENTERIC TUBERCULOSIS DRAINAGE UNIVERSAL AND
IMMUNOSUPPRESSED PATIENT ISOLATION
APPLICANTS WITH FORMAL NURSING EDUCATION MAY SUBMIT OFFICIAL TRANSCRIPTS FOR EVALUATION FOR POSSIBLE CREDIT IN LIEU OF PAID BEDSIDE NURSING EXPERIENCE THE TRANSCRIPTS MUST BE SUBMITTED TO THE BOARD DIRECTLY FROM THE SCHOOL AND MUST SHOW THEORY AND CLINICAL HOURS COMPLETED
4 NURSING SERVICE IN THE MEDICAL CORPS OF ANY BRANCH OF THE ARMED FORCES OF THE UNITED STATES THIS METHOD REQUIRES
A MILITARY SERVICE EVALUATIONS SHOWING AT LEAST TWELVE (12) MONTHS SERVICE ON ACTIVE DUTY IN THE MEDICAL CORPS OF ANY OF THE ARMED FORCES RENDERING BEDSIDE PATIENT CARE MILITARY SERVICE EVALUATIONS MUST BE SUBMITTED SHOWING THE DATES OF SERVICE WARDS ASSIGNED AND THE DUTIES PERFORMED FOR EACH ASSIGNMENT
B TRANSCRIPTS OR ldquoCERTIFICATE OF RELEASE OR DISCHARGE FROM ACTIVE DUTYrdquo (DD 214) SHOWING COMPLETION OF BASIC COURSE OF INSTRUCTION IN NURSING REQUIRED BY HIS OR HER PARTICULAR BRANCH OF THE ARMED FORCES
C DD 214 OR OTHER MILITARY DOCUMENT SHOWING THAT SERVICE IN THE ARMED FORCES HAS BEEN UNDER HONORABLE CONDITIONS OR WHOSE GENERAL DISCHARGE HAS BEEN UNDER HONORABLE CONDITIONS
NOTE A COMBINATION OF MILITARY AND NONMILITARY EXPERIENCE IS NOT ACCEPTABLE UNDER THIS METHOD PROOF OF 12TH
GRADE EDUCATION IS NOT REQUIRED UNDER THIS METHOD
NOTE STATE BOARDS OF NURSING IN MANY STATES REQUIRE GRADUATION FROM AN ACCREDITED SCHOOL OF NURSING PLEASE BE AWARE THAT APPLICANTS DEEMED ELIGIBLE FOR LICENSURE IN CALIFORNIA USING OTHER METHODS OF QUALIFYING (IE MILITARY EXPERIENCE OR EQUIVALENT EDUCATION AND EXPERIENCE) MAY NOT BE ELIGIBLE FOR LICENSURE BY ENDORSEMENT IN OTHER STATES
2
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
APPLICATION FOR VOCATIONAL NURSE LICENSURE
(ATTACH $150 APPLICATION FEE AN ADDITIONAL $49 FINGERPRINT FEE IS REQUIRED FOR PROCESSING ldquoHARD CARDrdquo FINGERPRINTS ndash SEE ENCLOSED INSTRUCTIONS )
Read all the enclosed instructions carefully before completing this application This information is required under Business and Professions Code Division 2 Chapter 65 Articles 1 and 2 The information you furnish will be used to determine your eligibility for licensure If additional space is needed to complete any section of this application please attach additional sheets The Executive Officer of the Board is responsible for information maintenance
PRINT OR TYPE (DO NOT USE PENCIL)
DO NOT WRITE IN THIS SPACE
APP NO
LIC NO
ILF-CA NO
ATS NO
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (MonthDayYear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBER Business (____)_________________________ Home (_____)_________________________
Area Code
7 DID YOU GRADUATE FROM HIGH SCHOOL YES NO NAME OF HIGH SCHOOL_______________________________ CITYSTATE_________________
DID YOU PASS A HIGH SCHOOL EQUIVALENCY TEST YES NO IF NO CIRCLE THE HIGHEST GRADE YOUCOMPLETED 1 2 3 4 5 6 7 8 9 10 11 12
8 DID YOU ATTEND A VOCATIONALPRACTICAL NURSING PROGRAM YES NO DID YOU GRADUATE FROM THE PROGRAM YES NO IF YES NAME OF VOCATIONALPRACTICAL NURSING PROGRAM DATE STARTED DATE COMPLETED STATE OR COUNTRY
_________________________________________________________ ________________ __________________ ___________________
9 DID YOU ATTEND A REGISTERED NURSING PROGRAM YES NO DID YOU GRADUATE FROM THE PROGRAM YES NO IF YES NAME OF REGISTERED NURSING PROGRAM DATE STARTED DATE COMPLETED STATE OR COUNTRY
_________________________________________________________ ________________ __________________ ________________
10 HAVE YOU EVER BEEN LICENSED AS A VOCATIONALPRACTICAL NURSE YES NO DATE LICENSED___________ STATE OF ORIGINAL LICENSE______
IF YES HAS THIS LICENSE EVER BEEN SUSPENDED REVOKED OR PLACED ON PROBATION YES NO (IF YES ATTACH EXPLANATION)
11 HAVE YOU EVER BEEN LICENSED AS A REGISTERED NURSE YES NO DATE LICENSED____________STATE OF ORIGINAL LICENSE____________
IF YES HAS THIS LICENSE EVER BEEN SUSPENDED REVOKED OR PLACED ON PROBATION YES NO (IF YES ATTACH EXPLANATION)
12 HAVE YOU EVER APPLIED TO THIS BOARD FOR LICENSURE UNDER A DIFFERENT NAME YES NO IF ldquoYESrdquo PLEASE LIST OTHER NAMES
WILL DOCUMENTS BE SUBMITTED TO THIS BOARD UNDER A DIFFERENT NAME YES NO IF YES PLEASE LIST OTHER NAMES
13 CONFIDENTIALITY NOTICE YOU ARE ADVISED THAT PURSUANT TO BUSINESS AND PROFESSIONS CODE SECTION 123 THE CONTENT OF THE VOCATIONAL NURSE LICENSURE EXAMINATION IS CONFIDENTIAL IF YOU ARE DEEMED ELIGIBLE TO TAKE THIS EXAMINATION YOU ARE HEREBY NOTIFIED THAT UNAUTHORIZED POSSESSION REPRODUCTION OR DISCLOSURE OF ANY EXAMINATION MATERIALS IS IN VIOLATION OF THE LAW AND SUBJECT TO CRIMINAL MISDEMEANOR PROSECUTION A VIOLAT ION OF THIS TYPE MAY ALSO RESULT IN CIVIL LIABILITY ANDOR DISCIPLINE BY THE LICENSING AGENCY INCLUDING THE DENIAL OF LICENSURE
14 PHOTOGRAPH REQUIREMENTS YOU MUST ATTACH A CURRENT FRONT VIEW HEAD AND SHOULDER PHOTOGRAPH OF YOURSELF IN A SEALED ENVELOPE THE PHOTOGRAPH SHOULD BE 2rdquo X 2rdquo AND MUST BE SIGNED ON THE BACK
15 PLEASE READ CAREFULLY BEFORE SIGNING ndash I hereby certify under penalty of perjury under the laws of the State of California that
the foregoing including any attachments is true and correct False statements included in this application can result in licensure denial
SIGNATURE_____________________________________________________________________ DATE___________ _____________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your Social Security Number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [(42 USCA (c ) (2) (C))] authorizes collection of your Social Security Number Your Social Security Number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your Social Security Number your application for initial license will not be processed and you will be reported to the Franchise Tax Board which may assess a $100 penalty against you
55A-1 (0312)
____
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
RECORD OF NURSING PROGRAM The applicant should complete the first section of this form and provide it to the Director of the nursing program The Director of the nursing program should complete the information in the second section and return it to the above address
THIS SECTION TO BE COMPLETED BY APPLICANT (ITEMS 1-6) PRINT OR TYPE (DO NOT USE PENCIL) 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (MonthDayYear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBERS BUSINESS ( )_________________________________ HOME ( )_________________________________
AREA CODE
THIS SECTION TO BE COMPLETED BY SCHOOLS OF VOCATIONAL PRACTICAL OR REGISTERED NURSING PRINT OR TYPE (DO NOT USE PENCIL)
7 NAME OF SCHOOL OF VOCATIONAL OR PRACTICAL NURSING CITY STATE
______________________________________________________________________ ______________________________________________________
DATE PROGRAM STARTED______________DATE PROGRAM COMPLETED______________ OR DATE VERIFIED HOURS WERE COMPLETED________________
WAS PROGRAM ldquoACCREDITEDrdquo WHEN HOURS WERE COMPLETED YES NO
8 NAME OF SCHOOL OF REGISTERED NURSING CITY STATE
_______________________________________________________________________ _______________________________________________________
DATE PROGRAM STARTED_____________ DATE PROGRAM COMPLETED_______________ OR DATE VERIFIED HOURS WERE COMPLETED________________
WAS PROGRAM ldquoACCREDITEDrdquo WHEN HOURS WERE COMPLETED YES NO
9 COMPLETION OF THE TW ELFTH (12TH) GRADE IN HIGH SCHOOL OR ITS EQUIVALENT HAS BEEN PROVEN BY THE APPLICANT AS FOLLOW S
PRESENTED OFFICIAL SCHOOL RECORDS SHOWING COMPLETION OF 12TH GRADE HIGH SCHOOL
PASSED THE ldquoGEDrdquo TEST AT THE 12TH GRADE LEVEL
10 A TOTAL NUMBER OF THEORYCLINICAL HOURS COMPLETED IN YOUR NURSING PROGRAM
THEORY__________HOURS CLINICAL__________HOURS
B TOTAL NUMBER OF THEORYCLINICAL HOURS WHICH YOUR SCHOOL GRANTED CREDIT FOR ldquoPREVIOUS EDUCATIONrdquo
THEORY__________HOURS CLINICAL__________HOURS
C COMPLETE THE SECOND PAGE OF THIS FORM IN FULL THIS IS A MANDATORY REQUIREMENT
11 I CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
SIGNATURE OF PROGRAM DIRECTOR_____________________________________________
(SCHOOL SEAL) PRINT PROGRAM DIRECTORrsquoS NAME_____________________________________________
DATE________________________________________________________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your social security number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [(42 USCA (c)(2)(C))] authorizes collection of your social security number Your social security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your social security number your application for initial license will not be processed and you will be reported to the Franchise Tax Board
55A-2 (208)
RECORD OF NURSING PROGRAM THIS SECTION OF THE FORM MUST BE COMPLETED IN FULL
1 NAME OF SCHOOL OF NURSING
___________________________________________________________
CHECK ONE
VOCATIONALPRACTICAL NURSING PROGRAM
REGISTERED NURSING PROGRAM
2 CITY 3 STATE AND COUNTRY
4 DATE PROGRAM STARTED ____________________________________
(MONTHDAYYEAR)
5 DATE VERIFIED HOURS WERE COMPLETED____________________________
(MONTHDAYYEAR)
6 SUBJECT ACTUAL HOURSUNITS COMPLETED CHECK HERE
IF SUBJECT IS
INTEGRATED
GRADE RECEIVED HOURSUNITS OF CREDIT GRANTED FOR PREVIOUS
LEARNING
THEORY CLINICAL THEORY CLINICAL THEORY CLINICAL
ANATOMY amp PHYSIOLOGY NA NA NA
NUTRITION NA NA NA
PHARMACOLOGY NA NA NA
PSYCHOLOGY NA NA NA
NORMAL GROWTH amp DEVELOPMENT
NA NA NA
NURSING FUNDAMENTALS
NURSING PROCESS
MEDICAL SURGICAL NURSING
COMMUNICABLE DISEASES
MATERNITY NURSING
PEDIATRIC NURSING
GERONTOLOGICAL NURSING
REHABILITATION NURSING
LEADERSHIP NA NA NA
SUPERVISION NA NA NA
COMMUNICATION NA NA NA
PATIENT EDUCATION NA NA NA
ETHICS amp UNETHICAL CONDUCT NA NA NA
CRITICAL THINKING NA NA NA
CULTURALLY CONGRUENT CARE
END OF LIFE CARE
TOTAL HOURS
____
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
RECORD OF NURSING EXPERIENCE PRINT OR TYPE (DO NOT USE PENCIL)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (monthdayyear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBERS BUSINESS ( )_________________________________ HOME ( )_________________________________
AREA CODE
EXPERIENCE List all nursing experience for the past ten (10) years for which you will be submitting verification of employment It is your responsibility to contact each employer and provide them with a copy of the Employment Verification ndash Nursing Experience Form for completion
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
_________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7B Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From _________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From _________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
NOTE IF MORE SPACE IS NEEDED PLEASE COMPLETE THE SECOND PAGE OF THIS FORM PLEASE READ CAREFULLY BEFORE SIGNING ndash I hereby certify under penalty of perjury under the laws of the State of California that the information
herein including any attachments is true and correct False statements included in this application can result in licensure denial
SIGNATURE_____________________________________________________________________ DATE________________________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your social security number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [42 USCA (c)(2)(C)] authorizes collection of your social security number Your social security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your social security number your application for initial license will not be processed and you will be reported to the Franchise Tax Board which may assess a $100 penalty against you
55A-3(408) 1
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
__________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7E Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7F Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7G Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7H Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7I Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
2
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROW N JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
In order to receive credit for nursing experience State law requires that the Board obtain verification of employment and certification from the Registered Nurse (RN) Director or Supervisor that the applicant has demonstrated the required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
INSTRUCTIONS TO APPLICANT
Complete Part I on the second page of this form and provide a copy of both pages to each employer for the past ten (10) years (You may reproduce as many copies of this form as needed)
This form must be completed in full by the RN Director or Supervisor and returned directly to you in the employerrsquos sealed business envelope The UNOPENED sealed envelopes containing the Employment Verification Forms must be submitted to the Board with your Application for Vocational Nurse Licensure
If you already have an application on the file with the Board and are submitting additional experience the employment verification form may be submitted to the Board by the applicant or the employer but must be received in the employerrsquos sealed business envelope
Please be advised that employment verification forms that appear to have been opened or altered will not be accepted The Board conducts random audits to verify the accuracy of the information submitted Discrepancies or false statements included in the application can result in licensure denial
INSTRUCTIONS TO EMPLOYER
The applicant on page two of this form is applying for licensure as a vocational nurse under Section 2873 of the Business and Professions Code In order for the applicant to receive credit for nursing experience State law requires the Board to obtain verification of employment and certification from the RN Director or Supervisor that the applicant has demonstrated required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
Please complete Parts II III and IV on page two of this form and return it to the applicant in a sealed business envelope Indicate on the outside of the envelope ldquoEmployment Verification Enclosed ndash Do Not Openrdquo It is the applicantrsquos responsibility to collect the Employment Verification Form(s) and submit them with the application for licensure
Part II Indicate the name and type of facility where the experience was obtained Part III Provide the specific dates that the applicant worked under your supervision in the area of
nursing being verified Additionally indicate if the applicant was employed full time (40 hrswk) or part time and include the number of hours worked in each area The Board MUST receive a breakdown of the number of hours spent in each area in order to evaluate the experience
Part IV Indicate whether the applicant has satisfactorily demonstrated each of the knowledge and skills with safety to the patient The skills listed in Part IV(B) may be demonstrated in classroom lab andor patient care settings
Thank you for your assistance Please feel free to contact the Board at (916) 263-7800 if you have any questions
55A-12 (Rev 1007) 1
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
Part I is to be completed by the applicant and submitted to employers for verification of nursing experience The remainder of this form must be completed by the RN Director or Supervisor and returned to the applicant by the employer in a sealed business envelope FORMS CONTAINING STRIKEOUTS OR CORRECTIONS WILL NOT BE ACCEPTED (See Page 1 for detailed instructions on how to complete this form)
Part I To be completed by the Applicant (print or type - do not use pencil)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 NAME WHILE EMPLOYED AT THIS FACILITY 5 SOCIAL SECURITY NUMBER
NOT required but may assist employer in locating records
6 DAYTIME TELEPHONE NUMBER
( )_________________________________ Area Code
Part II To be completed by the Employer - Indicate the name and type of facility where the experience was obtained
Name of facility where experience was obtained
Type of facility Acute or sub-acute(hospital) Home Health
Convalescent Skilled NursingLong Term Care Outpatient Clinicemergency care Other
Assisted Living
Part III To be completed by the Employer - Include dates and the area of nursing being verified Indicate if employment was full-time (40 hrswk) or part-time and include the total number of hours worked in each area
Areas of Bedside Nursing Experience Employment Period (MonthDateYear) Hours Worked
Per Week Total Hours In Each Area
For Office Use Only
Medical-Surgical Nursing From To Pediatric Nursing From To Maternity Nursing From To Genitourinary Nursing From To Psychiatric Nursing From To Office Nursing From To Long Term CareConvalescent From To Private Duty (in a general acute care facility) From To Other From To
Part IV To be completed by the Employer - Indicate if the applicant has satisfactorily demonstrated the following knowledge and skills with safety to the patient
Knowledge and Skills Demonstrated Knowledge and Skills Demonstrated YES NO YES NO
A Basic Bedside Nursing 1 Ambulation Techniques 9 Intake and Output 2 Bedmaking 10 Personal Hygiene and Comfort Measures 3 Urinary Catheter Care 11 Positioning and Transfer 4 Collection of Specimens 12 Range of Motion 5 Diabetic Testing 13 Skin Care 6 Administration of a Cleansing Enema 14 Vital Signs 7 Feeding Patient 15 Communication Skills Both Verbal and
Written Including Communication With Patients Who Have Psychological Disorders
8 Hot and Cold Applications
B Infection Control Procedures (may be demonstrated in classroom lab andor patient care settings) 1 Asepsis 2 Techniques for strict contact respiratory
enteric tuberculosis drainage universal and immunosuppressed patient isolation
TO BE SIGNED BY THE RN DIRECTOR OR SUPERVISOR I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
Signature ___________________________________________ Print Name___________________________________ Nursing License ___________________Exp Date__________ Telephone Number (_____)_ ____________________ Address _____________________________________________ Todayrsquos Date ________________________________ CityState ___________________________ Zip Code_______
55A-12 (Rev 1007) 2 Date Evaluated ____________ Initials ______
55A-6 (1015) - CONTINUED ON REVERSE -
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS RECORD OF CONVICTION
TYPE OR PRINT (USE BLUE OR BLACK INK ONLY) IF MORE SPACE IS NEEDED TO COMPLETE ANY SECTION PLEASE ATTACH ADDITIONAL SHEETS 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APARTMENT NUMBER)
3 CITY STATE ZIP
4 BIRTHDATE (MMDDYYYY) 6 TELEPHONE NUMBERS
CELL (_______) ________________________________________
HOME (_______) ________________________________________
BUSINESS (_______) ________________________________________
5 SOCIAL SECURITY OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER
7 Pursuant to Business and Professions Code Section 480 (c) any false statements included in this application may result in license denial Please carefully read all information contained on the front and back of this form before signing I declare under penalty of perjury under the laws of the State of California that the information provided herein and attachments is true and correct Signature ____________________________________________________________ Date ____________________________________
8 Are you or have you previously been licensed or certified as a psychiatric technician practical vocational or registered nurse or any other healthcare professional in this or any other state territory or country
Yes No
A
State
License Type
License
Expiration Date
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
B Has your license or certification ever been suspended revoked placed on probation or disciplined If Yes you must explain the basis for the disciplinary action and submit a copy of the disciplinary order
Yes No
C Have you used any other names If Yes list all other names used _______________________________________________________________
Yes No
9 Have you ever been convicted of pled guilty to or pled nolo contendere to ANY offense in the United States or a foreign country If YES you must complete item 12 on the back of this form
This includes every citation infraction misdemeanor andor felony excluding traffic violations under $1000 which do not involve alcohol dangerous drugs or controlled substances Convictions that were adjudicated in the juvenile court or convictions under California Health and Safety Code Sections 11357(b) (c) (d) (e) or Section 11360(b) which are two years or older should NOT be reported Convictions that were later dismissed pursuant to section 12034 12034a or 120341 of the California Penal Code or equivalent non-California law MUST be disclosed If you have obtained a dismissal of your conviction(s) pursuant to Penal Code sections 12034 12034(a) or 120341 please submit a certified copy of the court order dismissing the conviction(s) with your application
Yes No
10 Exclusive of juvenile court adjudications and criminal charges dismissed under section 10003 of the California Penal Code or equivalent non-California laws or convictions two years or older under California Health and Safety Code Sections 11357(b) (c) (d) (e) or section 11360(b) have you had a conviction that was set aside or later expunged from the records of the court If YES you must complete item 12 on the back of this form
Yes No
11 Is any court action pending against you or are you currently awaiting judgment and sentencing following entry of a plea or jury verdict If YES you must complete item 12 on the back of this form
Yes No
Important note You will be permitted to take the licensing examination regardless of any criminal conviction history you disclose However a determination as to whether your license will be granted or denied will not be made until you have passed the examination and the board has received all required conviction documentation
12 If you answered yes to item 9 10 or 11 you must provide all of the information requested below for each offense Department of Motor Vehicles printouts are not accepted in lieu of completing this section If more space is needed to complete this section please attach additional sheets
If you have been convicted of a crime you must submit certified court documents police reports and a detailed explanation in your own words for each offense (Certified courtpolice documents are obtained directly from the courtpolice department with an original stamp of certification Do not send copies as they will not contain an original certification and will not meet the requirement for certified documents If the police report andor court documents are no longer available you must obtain a statement from the police department or court attesting to that fact) Additionally please submit documents regarding your rehabilitation efforts such as
Proof that you complied with the terms of your parole probation restitution or any other court imposed sanctions Evidence of expungement proceedings pursuant to penal code section 12034 12034(a) or 120341 Any other evidence of rehabilitation you wish the board to consider
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
Notice on Collection of Personal Information For Applicants and Licensees
Collection and Use of Personal Information The Board of Vocational Nursing and Psychiatric Technicians (BVNPT) of the Department of Consumer Affairs (DCA) collects the personal information requested on this form as authorized by Business and Professions Code Section 30 (General Provisions) Business and Professions Code Division 2 Chapter 65 Articles 1 amp 2 (Vocational Nursing Practice Act) and Chapter 10 Articles 1 amp 2 (Psychiatric Technicians Law) and California Code of Regulations Title 16 Division 25 Chapter 1 (Vocational Nurses) and Chapter 2 (Psychiatric Technicians) The BVNPT uses this information principally to identify and evaluate applicants for licensure issue and renew licenses and enforce licensing standards set by law and regulation
Mandatory Submission Submission of the requested information is mandatory The BVNPT cannot consider your application for licensure or renewal unless you provide all of the requested information
Access to Personal Information You may review the records maintained by the BVNPT that contain your personal information as permitted by the Information Practices Act See below for contact information
Possible Disclosure of Personal Information The BVNPT makes every effort to protect the personal information you provide The information you provide however may be disclosed in the following circumstances
In response to a Public Records Act request (Government Code Section 6250 and following) as allowed by the Information Practices Act (Civil Code Section 1798 and following)
To another government agency as required or permitted by state or federal law or
In response to a court or administrative order a subpoena or a search warrant
Contact Information For questions about this notice or access to your records you may contact the BVNPT at 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833 (916) 263-7800 or email bvnptdcacagov
55P-1 (42109)
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
SUMMARY OF REQUIREMENTS FOR LICENSURE AS A VOCATIONAL NURSE
ALL APPLICANTS FOR LICENSURE AS A VOCATIONAL NURSE IN CALIFORNIA MUST MEET ALL OF THE REQUIREMENTS UNDER SECTION A AND ONE OF THE FOUR METHODS OF QUALIFYING FOR EXAMINATION IN SECTION B
SECTION A
1 BE AT LEAST 17 YEARS OF AGE
2 FURNISH PROOF OF COMPLETION OF THE 12TH GRADE OF SCHOOLING OR ITS EQUIVALENT
3 COMPLETE AND SIGN THE ldquoAPPLICATION FOR VOCATIONAL NURSE LICENSURErdquo AND FURNISH A VALID US SOCIAL SECURITY NUMBER
4 COMPLETE AND SIGN THE ldquoRECORD OF CONVICTIONrdquo FORM
5 NOT BE SUBJECT TO DENIAL PURSUANT TO BUSINESS amp PROFESSIONS CODE SECTION 480
6 SUBMIT THE REQUIRED DEPARTMENT OF JUSTICE (DOJ) AND FEDERAL BUREAU OF INVESTIGATION (FBI) FINGERPRINTS (SEE ENCLOSED ldquoIMPORTANT FINGERPRINT INFORMATIONrdquo) NOTE A LICENSE WILL NOT BE ISSUED UNTIL THE BOARD RECEIVES THE BACKGROUND INFORMATION FROM DOJ
7 ATTACH THE APPROPRIATE NONREFUNDABLE FEE MADE PAYABLE TO THE ldquoBVNPTrdquo (SEE PAGE 3 OF ENCLOSED ldquoINSTRUCTIONS TO APPLICANTS FOR LICENSURE AS A LICENSED VOCATIONAL NURSE)
8 SUCCESSFULLY COMPLETE A WRITTEN EXAMINATION TITLED ldquoNATIONAL COUNCIL LICENSING EXAMINATION FOR PRACTICAL (VOCATIONAL) NURSING (NCLEX PN)rdquo OR THE ldquoNATIONAL LEAGUE FOR NURSING TEST POOL PRACTICAL NURSING EXAMINATION (NLN)rdquo A PASSING SCORE ON A REGISTERED NURSE EXAMINATION WILL NOT SATISFY THIS REQUIREMENT
9 SUBMIT THE INITIAL LICENSE FEE WHEN YOU QUALIFY FOR LICENSURE THE BOARD WILL ADVISE YOU OF THE INITIAL LICENSE FEE TO BE PAID THIS FEE IS IN ADDITION TO THE APPLICATION FEE IT TAKES 4-6 WEEKS TO PROCESS YOUR LICENSE ONCE THIS FEE HAS BEEN RECEIVED
SECTION B - TO BE DEEMED ELIGIBLE FOR EXAMINATION YOU MUST QUALIFY BY ONE OF THE FOLLOWING METHODS
1 GRADUATE OF A CALIFORNIA ACCREDITED SCHOOL OF VOCATIONAL NURSING
YOU MUST HAVE SUCCESSFULLY COMPLETED A CALIFORNIA ACCREDITED VOCATIONAL NURSING PROGRAM
2 GRADUATE OF AN OUT-OF-STATE SCHOOL OF PRACTICALVOCATIONAL NURSING
THE SCHOOL OF PRACTICALVOCATIONAL NURSING FROM WHICH YOU GRADUATED MUST HAVE BEEN ACCREDITED BY THE BOARD OF NURSING IN THE STATE IN WHICH IT IS LOCATED AND THE COURSE CONTENT MUST HAVE BEEN SUBSTANTIALLY EQUIVALENT TO CALIFORNIA CURRICULUM REQUIREMENTS
LICENSURE IN ANOTHER STATE DOES NOT ENTITLE YOU TO PRACTICE AS A LICENSED VOCATIONAL NURSE IN CALIFORNIA IN ORDER TO PRACTICE AS A LICENSED VOCATIONAL NURSE IN CALIFORNIAYOU MUST BE LICENSED BY THE CALIFORNIA STATE BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS
55A-9 (108)
3 EQUIVALENT EDUCATION ANDOR EXPERIENCE
THIS METHOD REQUIRES YOU TO COMPLETE WITHIN TEN (10) YEARS PRIOR TO THE DATE OF APPLICATION NOT LESS THAN FIFTY-ONE (51) MONTHS OF PAID GENERAL DUTY INPATIENT BEDSIDE NURSING EXPERIENCE IN A CLINICAL FACILITY AT LEAST HALF OF WHICH SHALL HAVE BEEN WITHIN FIVE (5) YEARS PRIOR TO THE DATE OF APPLICATION PAID GENERAL DUTY INPATIENT BEDSIDE NURSING EXPERIENCE IS THE PERFORMANCE OF DIRECT PATIENT CARE FUNCTIONS PROVIDED THROUGHOUT THE PATIENTrsquoS STAY THAT ENCOMPASS THE BREADTH AND DEPTH OF EXPERIENCE EQUIVALENT TO THAT PERFORMED BY THE LICENSED VOCATIONAL NURSE YOU MUST ALSO COMPLETE A PHARMACOLOGY COURSE OF AT LEAST 54 THEORY HOURS
A THE PHARMACOLOGY COURSE (54 THEORY HOURS) SHALL INCLUDE BUT IS NOT LIMITED TO KNOWLEDGE OF COMMONLY USED DRUGS AND THEIR ACTION COMPUTATION OF DOSAGES PREPARATION OF MEDICATIONS PRINCIPLES OF ADMINISTRATION
B THE 51 MONTHS OF EXPERIENCE SHALL INCLUDE A MINIMUM OF EACH OF THE FOLLOWING 48 MONTHS MEDICALSURGICAL NURSING 6 WEEKS MATERNITY OR GENITOURINARY NURSING 6 WEEKS PEDIATRIC NURSING
C EXPERIENCE IN ANY OF THE FOLLOWING AREAS MAY BE SUBSTITUTED FOR A MAXIMUM OF EIGHT (8) MONTHS OF MEDICALSURGICAL EXPERIENCE
COMMUNICABLE DISEASE NURSING PRIVATE DUTY NURSING (IN AN ACUTE CARE FACILITY ONLY) PUBLIC HEALTH NURSING EMERGENCY ROOM NURSING OCCUPATIONAL HEALTH NURSING OUT PATIENT CLINIC OFFICE NURSING (MD) POST ANESTHESIA RECOVERY NURSING PSYCHIATRIC NURSING HEMODIALYSIS NURSING OPERATING ROOM NURSING REHABILITATION NURSING GERONTOLOGICAL NURSING EMERGENCY MEDICAL TECHNICIAN SERVICE
D EXPERIENCE MUST BE VERIFIED BY THE EMPLOYER SHOWING SPECIFIC DATES OF EMPLOYMENT AND SHALL INCLUDE CERTIFICATION FROM THE RN DIRECTOR OR SUPERVISOR THAT THE APPLICANT HAS SATISFACTORILY DEMONSTRATED THE FOLLOWING KNOWLEDGE AND SKILLS
1 BASIC BEDSIDE NURSING AMBULATION TECHNIQUES INTAKE AND OUTPUT BEDMAKING PERSONAL HYGIENE AND COMFORT MEASURES URINARY CATHETER CARE POSITIONING AND TRANSFER COLLECTION OF SPECIMENS RANGE OF MOTION DIABETIC TESTING SKIN CARE ADMINISTRATION OF A CLEANSING ENEMA VITAL SIGNS FEEDING PATIENT HOT AND COLD APPLICATIONS COMMUNICATION SKILLS BOTH VERBAL AND WRITTEN INCLUDING
COMMUNICATION WITH PATIENTS WHO HAVE PSYCHOLOGICAL DISORDERS
2 INFECTION CONTROL PROCEDURES (MAY BE DEMONSTRATED IN CLASSROOM LAB ANDOR PATIENT CARE SETTINGS)
ASEPSIS TECHNIQUES FOR STRICT CONTACT RESPIRATORY ENTERIC TUBERCULOSIS DRAINAGE UNIVERSAL AND
IMMUNOSUPPRESSED PATIENT ISOLATION
APPLICANTS WITH FORMAL NURSING EDUCATION MAY SUBMIT OFFICIAL TRANSCRIPTS FOR EVALUATION FOR POSSIBLE CREDIT IN LIEU OF PAID BEDSIDE NURSING EXPERIENCE THE TRANSCRIPTS MUST BE SUBMITTED TO THE BOARD DIRECTLY FROM THE SCHOOL AND MUST SHOW THEORY AND CLINICAL HOURS COMPLETED
4 NURSING SERVICE IN THE MEDICAL CORPS OF ANY BRANCH OF THE ARMED FORCES OF THE UNITED STATES THIS METHOD REQUIRES
A MILITARY SERVICE EVALUATIONS SHOWING AT LEAST TWELVE (12) MONTHS SERVICE ON ACTIVE DUTY IN THE MEDICAL CORPS OF ANY OF THE ARMED FORCES RENDERING BEDSIDE PATIENT CARE MILITARY SERVICE EVALUATIONS MUST BE SUBMITTED SHOWING THE DATES OF SERVICE WARDS ASSIGNED AND THE DUTIES PERFORMED FOR EACH ASSIGNMENT
B TRANSCRIPTS OR ldquoCERTIFICATE OF RELEASE OR DISCHARGE FROM ACTIVE DUTYrdquo (DD 214) SHOWING COMPLETION OF BASIC COURSE OF INSTRUCTION IN NURSING REQUIRED BY HIS OR HER PARTICULAR BRANCH OF THE ARMED FORCES
C DD 214 OR OTHER MILITARY DOCUMENT SHOWING THAT SERVICE IN THE ARMED FORCES HAS BEEN UNDER HONORABLE CONDITIONS OR WHOSE GENERAL DISCHARGE HAS BEEN UNDER HONORABLE CONDITIONS
NOTE A COMBINATION OF MILITARY AND NONMILITARY EXPERIENCE IS NOT ACCEPTABLE UNDER THIS METHOD PROOF OF 12TH
GRADE EDUCATION IS NOT REQUIRED UNDER THIS METHOD
NOTE STATE BOARDS OF NURSING IN MANY STATES REQUIRE GRADUATION FROM AN ACCREDITED SCHOOL OF NURSING PLEASE BE AWARE THAT APPLICANTS DEEMED ELIGIBLE FOR LICENSURE IN CALIFORNIA USING OTHER METHODS OF QUALIFYING (IE MILITARY EXPERIENCE OR EQUIVALENT EDUCATION AND EXPERIENCE) MAY NOT BE ELIGIBLE FOR LICENSURE BY ENDORSEMENT IN OTHER STATES
2
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
APPLICATION FOR VOCATIONAL NURSE LICENSURE
(ATTACH $150 APPLICATION FEE AN ADDITIONAL $49 FINGERPRINT FEE IS REQUIRED FOR PROCESSING ldquoHARD CARDrdquo FINGERPRINTS ndash SEE ENCLOSED INSTRUCTIONS )
Read all the enclosed instructions carefully before completing this application This information is required under Business and Professions Code Division 2 Chapter 65 Articles 1 and 2 The information you furnish will be used to determine your eligibility for licensure If additional space is needed to complete any section of this application please attach additional sheets The Executive Officer of the Board is responsible for information maintenance
PRINT OR TYPE (DO NOT USE PENCIL)
DO NOT WRITE IN THIS SPACE
APP NO
LIC NO
ILF-CA NO
ATS NO
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (MonthDayYear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBER Business (____)_________________________ Home (_____)_________________________
Area Code
7 DID YOU GRADUATE FROM HIGH SCHOOL YES NO NAME OF HIGH SCHOOL_______________________________ CITYSTATE_________________
DID YOU PASS A HIGH SCHOOL EQUIVALENCY TEST YES NO IF NO CIRCLE THE HIGHEST GRADE YOUCOMPLETED 1 2 3 4 5 6 7 8 9 10 11 12
8 DID YOU ATTEND A VOCATIONALPRACTICAL NURSING PROGRAM YES NO DID YOU GRADUATE FROM THE PROGRAM YES NO IF YES NAME OF VOCATIONALPRACTICAL NURSING PROGRAM DATE STARTED DATE COMPLETED STATE OR COUNTRY
_________________________________________________________ ________________ __________________ ___________________
9 DID YOU ATTEND A REGISTERED NURSING PROGRAM YES NO DID YOU GRADUATE FROM THE PROGRAM YES NO IF YES NAME OF REGISTERED NURSING PROGRAM DATE STARTED DATE COMPLETED STATE OR COUNTRY
_________________________________________________________ ________________ __________________ ________________
10 HAVE YOU EVER BEEN LICENSED AS A VOCATIONALPRACTICAL NURSE YES NO DATE LICENSED___________ STATE OF ORIGINAL LICENSE______
IF YES HAS THIS LICENSE EVER BEEN SUSPENDED REVOKED OR PLACED ON PROBATION YES NO (IF YES ATTACH EXPLANATION)
11 HAVE YOU EVER BEEN LICENSED AS A REGISTERED NURSE YES NO DATE LICENSED____________STATE OF ORIGINAL LICENSE____________
IF YES HAS THIS LICENSE EVER BEEN SUSPENDED REVOKED OR PLACED ON PROBATION YES NO (IF YES ATTACH EXPLANATION)
12 HAVE YOU EVER APPLIED TO THIS BOARD FOR LICENSURE UNDER A DIFFERENT NAME YES NO IF ldquoYESrdquo PLEASE LIST OTHER NAMES
WILL DOCUMENTS BE SUBMITTED TO THIS BOARD UNDER A DIFFERENT NAME YES NO IF YES PLEASE LIST OTHER NAMES
13 CONFIDENTIALITY NOTICE YOU ARE ADVISED THAT PURSUANT TO BUSINESS AND PROFESSIONS CODE SECTION 123 THE CONTENT OF THE VOCATIONAL NURSE LICENSURE EXAMINATION IS CONFIDENTIAL IF YOU ARE DEEMED ELIGIBLE TO TAKE THIS EXAMINATION YOU ARE HEREBY NOTIFIED THAT UNAUTHORIZED POSSESSION REPRODUCTION OR DISCLOSURE OF ANY EXAMINATION MATERIALS IS IN VIOLATION OF THE LAW AND SUBJECT TO CRIMINAL MISDEMEANOR PROSECUTION A VIOLAT ION OF THIS TYPE MAY ALSO RESULT IN CIVIL LIABILITY ANDOR DISCIPLINE BY THE LICENSING AGENCY INCLUDING THE DENIAL OF LICENSURE
14 PHOTOGRAPH REQUIREMENTS YOU MUST ATTACH A CURRENT FRONT VIEW HEAD AND SHOULDER PHOTOGRAPH OF YOURSELF IN A SEALED ENVELOPE THE PHOTOGRAPH SHOULD BE 2rdquo X 2rdquo AND MUST BE SIGNED ON THE BACK
15 PLEASE READ CAREFULLY BEFORE SIGNING ndash I hereby certify under penalty of perjury under the laws of the State of California that
the foregoing including any attachments is true and correct False statements included in this application can result in licensure denial
SIGNATURE_____________________________________________________________________ DATE___________ _____________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your Social Security Number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [(42 USCA (c ) (2) (C))] authorizes collection of your Social Security Number Your Social Security Number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your Social Security Number your application for initial license will not be processed and you will be reported to the Franchise Tax Board which may assess a $100 penalty against you
55A-1 (0312)
____
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
RECORD OF NURSING PROGRAM The applicant should complete the first section of this form and provide it to the Director of the nursing program The Director of the nursing program should complete the information in the second section and return it to the above address
THIS SECTION TO BE COMPLETED BY APPLICANT (ITEMS 1-6) PRINT OR TYPE (DO NOT USE PENCIL) 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (MonthDayYear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBERS BUSINESS ( )_________________________________ HOME ( )_________________________________
AREA CODE
THIS SECTION TO BE COMPLETED BY SCHOOLS OF VOCATIONAL PRACTICAL OR REGISTERED NURSING PRINT OR TYPE (DO NOT USE PENCIL)
7 NAME OF SCHOOL OF VOCATIONAL OR PRACTICAL NURSING CITY STATE
______________________________________________________________________ ______________________________________________________
DATE PROGRAM STARTED______________DATE PROGRAM COMPLETED______________ OR DATE VERIFIED HOURS WERE COMPLETED________________
WAS PROGRAM ldquoACCREDITEDrdquo WHEN HOURS WERE COMPLETED YES NO
8 NAME OF SCHOOL OF REGISTERED NURSING CITY STATE
_______________________________________________________________________ _______________________________________________________
DATE PROGRAM STARTED_____________ DATE PROGRAM COMPLETED_______________ OR DATE VERIFIED HOURS WERE COMPLETED________________
WAS PROGRAM ldquoACCREDITEDrdquo WHEN HOURS WERE COMPLETED YES NO
9 COMPLETION OF THE TW ELFTH (12TH) GRADE IN HIGH SCHOOL OR ITS EQUIVALENT HAS BEEN PROVEN BY THE APPLICANT AS FOLLOW S
PRESENTED OFFICIAL SCHOOL RECORDS SHOWING COMPLETION OF 12TH GRADE HIGH SCHOOL
PASSED THE ldquoGEDrdquo TEST AT THE 12TH GRADE LEVEL
10 A TOTAL NUMBER OF THEORYCLINICAL HOURS COMPLETED IN YOUR NURSING PROGRAM
THEORY__________HOURS CLINICAL__________HOURS
B TOTAL NUMBER OF THEORYCLINICAL HOURS WHICH YOUR SCHOOL GRANTED CREDIT FOR ldquoPREVIOUS EDUCATIONrdquo
THEORY__________HOURS CLINICAL__________HOURS
C COMPLETE THE SECOND PAGE OF THIS FORM IN FULL THIS IS A MANDATORY REQUIREMENT
11 I CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
SIGNATURE OF PROGRAM DIRECTOR_____________________________________________
(SCHOOL SEAL) PRINT PROGRAM DIRECTORrsquoS NAME_____________________________________________
DATE________________________________________________________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your social security number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [(42 USCA (c)(2)(C))] authorizes collection of your social security number Your social security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your social security number your application for initial license will not be processed and you will be reported to the Franchise Tax Board
55A-2 (208)
RECORD OF NURSING PROGRAM THIS SECTION OF THE FORM MUST BE COMPLETED IN FULL
1 NAME OF SCHOOL OF NURSING
___________________________________________________________
CHECK ONE
VOCATIONALPRACTICAL NURSING PROGRAM
REGISTERED NURSING PROGRAM
2 CITY 3 STATE AND COUNTRY
4 DATE PROGRAM STARTED ____________________________________
(MONTHDAYYEAR)
5 DATE VERIFIED HOURS WERE COMPLETED____________________________
(MONTHDAYYEAR)
6 SUBJECT ACTUAL HOURSUNITS COMPLETED CHECK HERE
IF SUBJECT IS
INTEGRATED
GRADE RECEIVED HOURSUNITS OF CREDIT GRANTED FOR PREVIOUS
LEARNING
THEORY CLINICAL THEORY CLINICAL THEORY CLINICAL
ANATOMY amp PHYSIOLOGY NA NA NA
NUTRITION NA NA NA
PHARMACOLOGY NA NA NA
PSYCHOLOGY NA NA NA
NORMAL GROWTH amp DEVELOPMENT
NA NA NA
NURSING FUNDAMENTALS
NURSING PROCESS
MEDICAL SURGICAL NURSING
COMMUNICABLE DISEASES
MATERNITY NURSING
PEDIATRIC NURSING
GERONTOLOGICAL NURSING
REHABILITATION NURSING
LEADERSHIP NA NA NA
SUPERVISION NA NA NA
COMMUNICATION NA NA NA
PATIENT EDUCATION NA NA NA
ETHICS amp UNETHICAL CONDUCT NA NA NA
CRITICAL THINKING NA NA NA
CULTURALLY CONGRUENT CARE
END OF LIFE CARE
TOTAL HOURS
____
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
RECORD OF NURSING EXPERIENCE PRINT OR TYPE (DO NOT USE PENCIL)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (monthdayyear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBERS BUSINESS ( )_________________________________ HOME ( )_________________________________
AREA CODE
EXPERIENCE List all nursing experience for the past ten (10) years for which you will be submitting verification of employment It is your responsibility to contact each employer and provide them with a copy of the Employment Verification ndash Nursing Experience Form for completion
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
_________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7B Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From _________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From _________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
NOTE IF MORE SPACE IS NEEDED PLEASE COMPLETE THE SECOND PAGE OF THIS FORM PLEASE READ CAREFULLY BEFORE SIGNING ndash I hereby certify under penalty of perjury under the laws of the State of California that the information
herein including any attachments is true and correct False statements included in this application can result in licensure denial
SIGNATURE_____________________________________________________________________ DATE________________________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your social security number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [42 USCA (c)(2)(C)] authorizes collection of your social security number Your social security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your social security number your application for initial license will not be processed and you will be reported to the Franchise Tax Board which may assess a $100 penalty against you
55A-3(408) 1
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
__________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7E Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7F Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7G Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7H Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7I Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
2
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROW N JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
In order to receive credit for nursing experience State law requires that the Board obtain verification of employment and certification from the Registered Nurse (RN) Director or Supervisor that the applicant has demonstrated the required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
INSTRUCTIONS TO APPLICANT
Complete Part I on the second page of this form and provide a copy of both pages to each employer for the past ten (10) years (You may reproduce as many copies of this form as needed)
This form must be completed in full by the RN Director or Supervisor and returned directly to you in the employerrsquos sealed business envelope The UNOPENED sealed envelopes containing the Employment Verification Forms must be submitted to the Board with your Application for Vocational Nurse Licensure
If you already have an application on the file with the Board and are submitting additional experience the employment verification form may be submitted to the Board by the applicant or the employer but must be received in the employerrsquos sealed business envelope
Please be advised that employment verification forms that appear to have been opened or altered will not be accepted The Board conducts random audits to verify the accuracy of the information submitted Discrepancies or false statements included in the application can result in licensure denial
INSTRUCTIONS TO EMPLOYER
The applicant on page two of this form is applying for licensure as a vocational nurse under Section 2873 of the Business and Professions Code In order for the applicant to receive credit for nursing experience State law requires the Board to obtain verification of employment and certification from the RN Director or Supervisor that the applicant has demonstrated required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
Please complete Parts II III and IV on page two of this form and return it to the applicant in a sealed business envelope Indicate on the outside of the envelope ldquoEmployment Verification Enclosed ndash Do Not Openrdquo It is the applicantrsquos responsibility to collect the Employment Verification Form(s) and submit them with the application for licensure
Part II Indicate the name and type of facility where the experience was obtained Part III Provide the specific dates that the applicant worked under your supervision in the area of
nursing being verified Additionally indicate if the applicant was employed full time (40 hrswk) or part time and include the number of hours worked in each area The Board MUST receive a breakdown of the number of hours spent in each area in order to evaluate the experience
Part IV Indicate whether the applicant has satisfactorily demonstrated each of the knowledge and skills with safety to the patient The skills listed in Part IV(B) may be demonstrated in classroom lab andor patient care settings
Thank you for your assistance Please feel free to contact the Board at (916) 263-7800 if you have any questions
55A-12 (Rev 1007) 1
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
Part I is to be completed by the applicant and submitted to employers for verification of nursing experience The remainder of this form must be completed by the RN Director or Supervisor and returned to the applicant by the employer in a sealed business envelope FORMS CONTAINING STRIKEOUTS OR CORRECTIONS WILL NOT BE ACCEPTED (See Page 1 for detailed instructions on how to complete this form)
Part I To be completed by the Applicant (print or type - do not use pencil)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 NAME WHILE EMPLOYED AT THIS FACILITY 5 SOCIAL SECURITY NUMBER
NOT required but may assist employer in locating records
6 DAYTIME TELEPHONE NUMBER
( )_________________________________ Area Code
Part II To be completed by the Employer - Indicate the name and type of facility where the experience was obtained
Name of facility where experience was obtained
Type of facility Acute or sub-acute(hospital) Home Health
Convalescent Skilled NursingLong Term Care Outpatient Clinicemergency care Other
Assisted Living
Part III To be completed by the Employer - Include dates and the area of nursing being verified Indicate if employment was full-time (40 hrswk) or part-time and include the total number of hours worked in each area
Areas of Bedside Nursing Experience Employment Period (MonthDateYear) Hours Worked
Per Week Total Hours In Each Area
For Office Use Only
Medical-Surgical Nursing From To Pediatric Nursing From To Maternity Nursing From To Genitourinary Nursing From To Psychiatric Nursing From To Office Nursing From To Long Term CareConvalescent From To Private Duty (in a general acute care facility) From To Other From To
Part IV To be completed by the Employer - Indicate if the applicant has satisfactorily demonstrated the following knowledge and skills with safety to the patient
Knowledge and Skills Demonstrated Knowledge and Skills Demonstrated YES NO YES NO
A Basic Bedside Nursing 1 Ambulation Techniques 9 Intake and Output 2 Bedmaking 10 Personal Hygiene and Comfort Measures 3 Urinary Catheter Care 11 Positioning and Transfer 4 Collection of Specimens 12 Range of Motion 5 Diabetic Testing 13 Skin Care 6 Administration of a Cleansing Enema 14 Vital Signs 7 Feeding Patient 15 Communication Skills Both Verbal and
Written Including Communication With Patients Who Have Psychological Disorders
8 Hot and Cold Applications
B Infection Control Procedures (may be demonstrated in classroom lab andor patient care settings) 1 Asepsis 2 Techniques for strict contact respiratory
enteric tuberculosis drainage universal and immunosuppressed patient isolation
TO BE SIGNED BY THE RN DIRECTOR OR SUPERVISOR I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
Signature ___________________________________________ Print Name___________________________________ Nursing License ___________________Exp Date__________ Telephone Number (_____)_ ____________________ Address _____________________________________________ Todayrsquos Date ________________________________ CityState ___________________________ Zip Code_______
55A-12 (Rev 1007) 2 Date Evaluated ____________ Initials ______
55A-6 (1015) - CONTINUED ON REVERSE -
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS RECORD OF CONVICTION
TYPE OR PRINT (USE BLUE OR BLACK INK ONLY) IF MORE SPACE IS NEEDED TO COMPLETE ANY SECTION PLEASE ATTACH ADDITIONAL SHEETS 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APARTMENT NUMBER)
3 CITY STATE ZIP
4 BIRTHDATE (MMDDYYYY) 6 TELEPHONE NUMBERS
CELL (_______) ________________________________________
HOME (_______) ________________________________________
BUSINESS (_______) ________________________________________
5 SOCIAL SECURITY OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER
7 Pursuant to Business and Professions Code Section 480 (c) any false statements included in this application may result in license denial Please carefully read all information contained on the front and back of this form before signing I declare under penalty of perjury under the laws of the State of California that the information provided herein and attachments is true and correct Signature ____________________________________________________________ Date ____________________________________
8 Are you or have you previously been licensed or certified as a psychiatric technician practical vocational or registered nurse or any other healthcare professional in this or any other state territory or country
Yes No
A
State
License Type
License
Expiration Date
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
B Has your license or certification ever been suspended revoked placed on probation or disciplined If Yes you must explain the basis for the disciplinary action and submit a copy of the disciplinary order
Yes No
C Have you used any other names If Yes list all other names used _______________________________________________________________
Yes No
9 Have you ever been convicted of pled guilty to or pled nolo contendere to ANY offense in the United States or a foreign country If YES you must complete item 12 on the back of this form
This includes every citation infraction misdemeanor andor felony excluding traffic violations under $1000 which do not involve alcohol dangerous drugs or controlled substances Convictions that were adjudicated in the juvenile court or convictions under California Health and Safety Code Sections 11357(b) (c) (d) (e) or Section 11360(b) which are two years or older should NOT be reported Convictions that were later dismissed pursuant to section 12034 12034a or 120341 of the California Penal Code or equivalent non-California law MUST be disclosed If you have obtained a dismissal of your conviction(s) pursuant to Penal Code sections 12034 12034(a) or 120341 please submit a certified copy of the court order dismissing the conviction(s) with your application
Yes No
10 Exclusive of juvenile court adjudications and criminal charges dismissed under section 10003 of the California Penal Code or equivalent non-California laws or convictions two years or older under California Health and Safety Code Sections 11357(b) (c) (d) (e) or section 11360(b) have you had a conviction that was set aside or later expunged from the records of the court If YES you must complete item 12 on the back of this form
Yes No
11 Is any court action pending against you or are you currently awaiting judgment and sentencing following entry of a plea or jury verdict If YES you must complete item 12 on the back of this form
Yes No
Important note You will be permitted to take the licensing examination regardless of any criminal conviction history you disclose However a determination as to whether your license will be granted or denied will not be made until you have passed the examination and the board has received all required conviction documentation
12 If you answered yes to item 9 10 or 11 you must provide all of the information requested below for each offense Department of Motor Vehicles printouts are not accepted in lieu of completing this section If more space is needed to complete this section please attach additional sheets
If you have been convicted of a crime you must submit certified court documents police reports and a detailed explanation in your own words for each offense (Certified courtpolice documents are obtained directly from the courtpolice department with an original stamp of certification Do not send copies as they will not contain an original certification and will not meet the requirement for certified documents If the police report andor court documents are no longer available you must obtain a statement from the police department or court attesting to that fact) Additionally please submit documents regarding your rehabilitation efforts such as
Proof that you complied with the terms of your parole probation restitution or any other court imposed sanctions Evidence of expungement proceedings pursuant to penal code section 12034 12034(a) or 120341 Any other evidence of rehabilitation you wish the board to consider
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
Notice on Collection of Personal Information For Applicants and Licensees
Collection and Use of Personal Information The Board of Vocational Nursing and Psychiatric Technicians (BVNPT) of the Department of Consumer Affairs (DCA) collects the personal information requested on this form as authorized by Business and Professions Code Section 30 (General Provisions) Business and Professions Code Division 2 Chapter 65 Articles 1 amp 2 (Vocational Nursing Practice Act) and Chapter 10 Articles 1 amp 2 (Psychiatric Technicians Law) and California Code of Regulations Title 16 Division 25 Chapter 1 (Vocational Nurses) and Chapter 2 (Psychiatric Technicians) The BVNPT uses this information principally to identify and evaluate applicants for licensure issue and renew licenses and enforce licensing standards set by law and regulation
Mandatory Submission Submission of the requested information is mandatory The BVNPT cannot consider your application for licensure or renewal unless you provide all of the requested information
Access to Personal Information You may review the records maintained by the BVNPT that contain your personal information as permitted by the Information Practices Act See below for contact information
Possible Disclosure of Personal Information The BVNPT makes every effort to protect the personal information you provide The information you provide however may be disclosed in the following circumstances
In response to a Public Records Act request (Government Code Section 6250 and following) as allowed by the Information Practices Act (Civil Code Section 1798 and following)
To another government agency as required or permitted by state or federal law or
In response to a court or administrative order a subpoena or a search warrant
Contact Information For questions about this notice or access to your records you may contact the BVNPT at 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833 (916) 263-7800 or email bvnptdcacagov
55P-1 (42109)
3 EQUIVALENT EDUCATION ANDOR EXPERIENCE
THIS METHOD REQUIRES YOU TO COMPLETE WITHIN TEN (10) YEARS PRIOR TO THE DATE OF APPLICATION NOT LESS THAN FIFTY-ONE (51) MONTHS OF PAID GENERAL DUTY INPATIENT BEDSIDE NURSING EXPERIENCE IN A CLINICAL FACILITY AT LEAST HALF OF WHICH SHALL HAVE BEEN WITHIN FIVE (5) YEARS PRIOR TO THE DATE OF APPLICATION PAID GENERAL DUTY INPATIENT BEDSIDE NURSING EXPERIENCE IS THE PERFORMANCE OF DIRECT PATIENT CARE FUNCTIONS PROVIDED THROUGHOUT THE PATIENTrsquoS STAY THAT ENCOMPASS THE BREADTH AND DEPTH OF EXPERIENCE EQUIVALENT TO THAT PERFORMED BY THE LICENSED VOCATIONAL NURSE YOU MUST ALSO COMPLETE A PHARMACOLOGY COURSE OF AT LEAST 54 THEORY HOURS
A THE PHARMACOLOGY COURSE (54 THEORY HOURS) SHALL INCLUDE BUT IS NOT LIMITED TO KNOWLEDGE OF COMMONLY USED DRUGS AND THEIR ACTION COMPUTATION OF DOSAGES PREPARATION OF MEDICATIONS PRINCIPLES OF ADMINISTRATION
B THE 51 MONTHS OF EXPERIENCE SHALL INCLUDE A MINIMUM OF EACH OF THE FOLLOWING 48 MONTHS MEDICALSURGICAL NURSING 6 WEEKS MATERNITY OR GENITOURINARY NURSING 6 WEEKS PEDIATRIC NURSING
C EXPERIENCE IN ANY OF THE FOLLOWING AREAS MAY BE SUBSTITUTED FOR A MAXIMUM OF EIGHT (8) MONTHS OF MEDICALSURGICAL EXPERIENCE
COMMUNICABLE DISEASE NURSING PRIVATE DUTY NURSING (IN AN ACUTE CARE FACILITY ONLY) PUBLIC HEALTH NURSING EMERGENCY ROOM NURSING OCCUPATIONAL HEALTH NURSING OUT PATIENT CLINIC OFFICE NURSING (MD) POST ANESTHESIA RECOVERY NURSING PSYCHIATRIC NURSING HEMODIALYSIS NURSING OPERATING ROOM NURSING REHABILITATION NURSING GERONTOLOGICAL NURSING EMERGENCY MEDICAL TECHNICIAN SERVICE
D EXPERIENCE MUST BE VERIFIED BY THE EMPLOYER SHOWING SPECIFIC DATES OF EMPLOYMENT AND SHALL INCLUDE CERTIFICATION FROM THE RN DIRECTOR OR SUPERVISOR THAT THE APPLICANT HAS SATISFACTORILY DEMONSTRATED THE FOLLOWING KNOWLEDGE AND SKILLS
1 BASIC BEDSIDE NURSING AMBULATION TECHNIQUES INTAKE AND OUTPUT BEDMAKING PERSONAL HYGIENE AND COMFORT MEASURES URINARY CATHETER CARE POSITIONING AND TRANSFER COLLECTION OF SPECIMENS RANGE OF MOTION DIABETIC TESTING SKIN CARE ADMINISTRATION OF A CLEANSING ENEMA VITAL SIGNS FEEDING PATIENT HOT AND COLD APPLICATIONS COMMUNICATION SKILLS BOTH VERBAL AND WRITTEN INCLUDING
COMMUNICATION WITH PATIENTS WHO HAVE PSYCHOLOGICAL DISORDERS
2 INFECTION CONTROL PROCEDURES (MAY BE DEMONSTRATED IN CLASSROOM LAB ANDOR PATIENT CARE SETTINGS)
ASEPSIS TECHNIQUES FOR STRICT CONTACT RESPIRATORY ENTERIC TUBERCULOSIS DRAINAGE UNIVERSAL AND
IMMUNOSUPPRESSED PATIENT ISOLATION
APPLICANTS WITH FORMAL NURSING EDUCATION MAY SUBMIT OFFICIAL TRANSCRIPTS FOR EVALUATION FOR POSSIBLE CREDIT IN LIEU OF PAID BEDSIDE NURSING EXPERIENCE THE TRANSCRIPTS MUST BE SUBMITTED TO THE BOARD DIRECTLY FROM THE SCHOOL AND MUST SHOW THEORY AND CLINICAL HOURS COMPLETED
4 NURSING SERVICE IN THE MEDICAL CORPS OF ANY BRANCH OF THE ARMED FORCES OF THE UNITED STATES THIS METHOD REQUIRES
A MILITARY SERVICE EVALUATIONS SHOWING AT LEAST TWELVE (12) MONTHS SERVICE ON ACTIVE DUTY IN THE MEDICAL CORPS OF ANY OF THE ARMED FORCES RENDERING BEDSIDE PATIENT CARE MILITARY SERVICE EVALUATIONS MUST BE SUBMITTED SHOWING THE DATES OF SERVICE WARDS ASSIGNED AND THE DUTIES PERFORMED FOR EACH ASSIGNMENT
B TRANSCRIPTS OR ldquoCERTIFICATE OF RELEASE OR DISCHARGE FROM ACTIVE DUTYrdquo (DD 214) SHOWING COMPLETION OF BASIC COURSE OF INSTRUCTION IN NURSING REQUIRED BY HIS OR HER PARTICULAR BRANCH OF THE ARMED FORCES
C DD 214 OR OTHER MILITARY DOCUMENT SHOWING THAT SERVICE IN THE ARMED FORCES HAS BEEN UNDER HONORABLE CONDITIONS OR WHOSE GENERAL DISCHARGE HAS BEEN UNDER HONORABLE CONDITIONS
NOTE A COMBINATION OF MILITARY AND NONMILITARY EXPERIENCE IS NOT ACCEPTABLE UNDER THIS METHOD PROOF OF 12TH
GRADE EDUCATION IS NOT REQUIRED UNDER THIS METHOD
NOTE STATE BOARDS OF NURSING IN MANY STATES REQUIRE GRADUATION FROM AN ACCREDITED SCHOOL OF NURSING PLEASE BE AWARE THAT APPLICANTS DEEMED ELIGIBLE FOR LICENSURE IN CALIFORNIA USING OTHER METHODS OF QUALIFYING (IE MILITARY EXPERIENCE OR EQUIVALENT EDUCATION AND EXPERIENCE) MAY NOT BE ELIGIBLE FOR LICENSURE BY ENDORSEMENT IN OTHER STATES
2
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
APPLICATION FOR VOCATIONAL NURSE LICENSURE
(ATTACH $150 APPLICATION FEE AN ADDITIONAL $49 FINGERPRINT FEE IS REQUIRED FOR PROCESSING ldquoHARD CARDrdquo FINGERPRINTS ndash SEE ENCLOSED INSTRUCTIONS )
Read all the enclosed instructions carefully before completing this application This information is required under Business and Professions Code Division 2 Chapter 65 Articles 1 and 2 The information you furnish will be used to determine your eligibility for licensure If additional space is needed to complete any section of this application please attach additional sheets The Executive Officer of the Board is responsible for information maintenance
PRINT OR TYPE (DO NOT USE PENCIL)
DO NOT WRITE IN THIS SPACE
APP NO
LIC NO
ILF-CA NO
ATS NO
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (MonthDayYear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBER Business (____)_________________________ Home (_____)_________________________
Area Code
7 DID YOU GRADUATE FROM HIGH SCHOOL YES NO NAME OF HIGH SCHOOL_______________________________ CITYSTATE_________________
DID YOU PASS A HIGH SCHOOL EQUIVALENCY TEST YES NO IF NO CIRCLE THE HIGHEST GRADE YOUCOMPLETED 1 2 3 4 5 6 7 8 9 10 11 12
8 DID YOU ATTEND A VOCATIONALPRACTICAL NURSING PROGRAM YES NO DID YOU GRADUATE FROM THE PROGRAM YES NO IF YES NAME OF VOCATIONALPRACTICAL NURSING PROGRAM DATE STARTED DATE COMPLETED STATE OR COUNTRY
_________________________________________________________ ________________ __________________ ___________________
9 DID YOU ATTEND A REGISTERED NURSING PROGRAM YES NO DID YOU GRADUATE FROM THE PROGRAM YES NO IF YES NAME OF REGISTERED NURSING PROGRAM DATE STARTED DATE COMPLETED STATE OR COUNTRY
_________________________________________________________ ________________ __________________ ________________
10 HAVE YOU EVER BEEN LICENSED AS A VOCATIONALPRACTICAL NURSE YES NO DATE LICENSED___________ STATE OF ORIGINAL LICENSE______
IF YES HAS THIS LICENSE EVER BEEN SUSPENDED REVOKED OR PLACED ON PROBATION YES NO (IF YES ATTACH EXPLANATION)
11 HAVE YOU EVER BEEN LICENSED AS A REGISTERED NURSE YES NO DATE LICENSED____________STATE OF ORIGINAL LICENSE____________
IF YES HAS THIS LICENSE EVER BEEN SUSPENDED REVOKED OR PLACED ON PROBATION YES NO (IF YES ATTACH EXPLANATION)
12 HAVE YOU EVER APPLIED TO THIS BOARD FOR LICENSURE UNDER A DIFFERENT NAME YES NO IF ldquoYESrdquo PLEASE LIST OTHER NAMES
WILL DOCUMENTS BE SUBMITTED TO THIS BOARD UNDER A DIFFERENT NAME YES NO IF YES PLEASE LIST OTHER NAMES
13 CONFIDENTIALITY NOTICE YOU ARE ADVISED THAT PURSUANT TO BUSINESS AND PROFESSIONS CODE SECTION 123 THE CONTENT OF THE VOCATIONAL NURSE LICENSURE EXAMINATION IS CONFIDENTIAL IF YOU ARE DEEMED ELIGIBLE TO TAKE THIS EXAMINATION YOU ARE HEREBY NOTIFIED THAT UNAUTHORIZED POSSESSION REPRODUCTION OR DISCLOSURE OF ANY EXAMINATION MATERIALS IS IN VIOLATION OF THE LAW AND SUBJECT TO CRIMINAL MISDEMEANOR PROSECUTION A VIOLAT ION OF THIS TYPE MAY ALSO RESULT IN CIVIL LIABILITY ANDOR DISCIPLINE BY THE LICENSING AGENCY INCLUDING THE DENIAL OF LICENSURE
14 PHOTOGRAPH REQUIREMENTS YOU MUST ATTACH A CURRENT FRONT VIEW HEAD AND SHOULDER PHOTOGRAPH OF YOURSELF IN A SEALED ENVELOPE THE PHOTOGRAPH SHOULD BE 2rdquo X 2rdquo AND MUST BE SIGNED ON THE BACK
15 PLEASE READ CAREFULLY BEFORE SIGNING ndash I hereby certify under penalty of perjury under the laws of the State of California that
the foregoing including any attachments is true and correct False statements included in this application can result in licensure denial
SIGNATURE_____________________________________________________________________ DATE___________ _____________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your Social Security Number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [(42 USCA (c ) (2) (C))] authorizes collection of your Social Security Number Your Social Security Number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your Social Security Number your application for initial license will not be processed and you will be reported to the Franchise Tax Board which may assess a $100 penalty against you
55A-1 (0312)
____
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
RECORD OF NURSING PROGRAM The applicant should complete the first section of this form and provide it to the Director of the nursing program The Director of the nursing program should complete the information in the second section and return it to the above address
THIS SECTION TO BE COMPLETED BY APPLICANT (ITEMS 1-6) PRINT OR TYPE (DO NOT USE PENCIL) 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (MonthDayYear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBERS BUSINESS ( )_________________________________ HOME ( )_________________________________
AREA CODE
THIS SECTION TO BE COMPLETED BY SCHOOLS OF VOCATIONAL PRACTICAL OR REGISTERED NURSING PRINT OR TYPE (DO NOT USE PENCIL)
7 NAME OF SCHOOL OF VOCATIONAL OR PRACTICAL NURSING CITY STATE
______________________________________________________________________ ______________________________________________________
DATE PROGRAM STARTED______________DATE PROGRAM COMPLETED______________ OR DATE VERIFIED HOURS WERE COMPLETED________________
WAS PROGRAM ldquoACCREDITEDrdquo WHEN HOURS WERE COMPLETED YES NO
8 NAME OF SCHOOL OF REGISTERED NURSING CITY STATE
_______________________________________________________________________ _______________________________________________________
DATE PROGRAM STARTED_____________ DATE PROGRAM COMPLETED_______________ OR DATE VERIFIED HOURS WERE COMPLETED________________
WAS PROGRAM ldquoACCREDITEDrdquo WHEN HOURS WERE COMPLETED YES NO
9 COMPLETION OF THE TW ELFTH (12TH) GRADE IN HIGH SCHOOL OR ITS EQUIVALENT HAS BEEN PROVEN BY THE APPLICANT AS FOLLOW S
PRESENTED OFFICIAL SCHOOL RECORDS SHOWING COMPLETION OF 12TH GRADE HIGH SCHOOL
PASSED THE ldquoGEDrdquo TEST AT THE 12TH GRADE LEVEL
10 A TOTAL NUMBER OF THEORYCLINICAL HOURS COMPLETED IN YOUR NURSING PROGRAM
THEORY__________HOURS CLINICAL__________HOURS
B TOTAL NUMBER OF THEORYCLINICAL HOURS WHICH YOUR SCHOOL GRANTED CREDIT FOR ldquoPREVIOUS EDUCATIONrdquo
THEORY__________HOURS CLINICAL__________HOURS
C COMPLETE THE SECOND PAGE OF THIS FORM IN FULL THIS IS A MANDATORY REQUIREMENT
11 I CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
SIGNATURE OF PROGRAM DIRECTOR_____________________________________________
(SCHOOL SEAL) PRINT PROGRAM DIRECTORrsquoS NAME_____________________________________________
DATE________________________________________________________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your social security number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [(42 USCA (c)(2)(C))] authorizes collection of your social security number Your social security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your social security number your application for initial license will not be processed and you will be reported to the Franchise Tax Board
55A-2 (208)
RECORD OF NURSING PROGRAM THIS SECTION OF THE FORM MUST BE COMPLETED IN FULL
1 NAME OF SCHOOL OF NURSING
___________________________________________________________
CHECK ONE
VOCATIONALPRACTICAL NURSING PROGRAM
REGISTERED NURSING PROGRAM
2 CITY 3 STATE AND COUNTRY
4 DATE PROGRAM STARTED ____________________________________
(MONTHDAYYEAR)
5 DATE VERIFIED HOURS WERE COMPLETED____________________________
(MONTHDAYYEAR)
6 SUBJECT ACTUAL HOURSUNITS COMPLETED CHECK HERE
IF SUBJECT IS
INTEGRATED
GRADE RECEIVED HOURSUNITS OF CREDIT GRANTED FOR PREVIOUS
LEARNING
THEORY CLINICAL THEORY CLINICAL THEORY CLINICAL
ANATOMY amp PHYSIOLOGY NA NA NA
NUTRITION NA NA NA
PHARMACOLOGY NA NA NA
PSYCHOLOGY NA NA NA
NORMAL GROWTH amp DEVELOPMENT
NA NA NA
NURSING FUNDAMENTALS
NURSING PROCESS
MEDICAL SURGICAL NURSING
COMMUNICABLE DISEASES
MATERNITY NURSING
PEDIATRIC NURSING
GERONTOLOGICAL NURSING
REHABILITATION NURSING
LEADERSHIP NA NA NA
SUPERVISION NA NA NA
COMMUNICATION NA NA NA
PATIENT EDUCATION NA NA NA
ETHICS amp UNETHICAL CONDUCT NA NA NA
CRITICAL THINKING NA NA NA
CULTURALLY CONGRUENT CARE
END OF LIFE CARE
TOTAL HOURS
____
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
RECORD OF NURSING EXPERIENCE PRINT OR TYPE (DO NOT USE PENCIL)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (monthdayyear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBERS BUSINESS ( )_________________________________ HOME ( )_________________________________
AREA CODE
EXPERIENCE List all nursing experience for the past ten (10) years for which you will be submitting verification of employment It is your responsibility to contact each employer and provide them with a copy of the Employment Verification ndash Nursing Experience Form for completion
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
_________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7B Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From _________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From _________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
NOTE IF MORE SPACE IS NEEDED PLEASE COMPLETE THE SECOND PAGE OF THIS FORM PLEASE READ CAREFULLY BEFORE SIGNING ndash I hereby certify under penalty of perjury under the laws of the State of California that the information
herein including any attachments is true and correct False statements included in this application can result in licensure denial
SIGNATURE_____________________________________________________________________ DATE________________________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your social security number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [42 USCA (c)(2)(C)] authorizes collection of your social security number Your social security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your social security number your application for initial license will not be processed and you will be reported to the Franchise Tax Board which may assess a $100 penalty against you
55A-3(408) 1
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
__________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7E Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7F Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7G Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7H Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7I Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
2
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROW N JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
In order to receive credit for nursing experience State law requires that the Board obtain verification of employment and certification from the Registered Nurse (RN) Director or Supervisor that the applicant has demonstrated the required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
INSTRUCTIONS TO APPLICANT
Complete Part I on the second page of this form and provide a copy of both pages to each employer for the past ten (10) years (You may reproduce as many copies of this form as needed)
This form must be completed in full by the RN Director or Supervisor and returned directly to you in the employerrsquos sealed business envelope The UNOPENED sealed envelopes containing the Employment Verification Forms must be submitted to the Board with your Application for Vocational Nurse Licensure
If you already have an application on the file with the Board and are submitting additional experience the employment verification form may be submitted to the Board by the applicant or the employer but must be received in the employerrsquos sealed business envelope
Please be advised that employment verification forms that appear to have been opened or altered will not be accepted The Board conducts random audits to verify the accuracy of the information submitted Discrepancies or false statements included in the application can result in licensure denial
INSTRUCTIONS TO EMPLOYER
The applicant on page two of this form is applying for licensure as a vocational nurse under Section 2873 of the Business and Professions Code In order for the applicant to receive credit for nursing experience State law requires the Board to obtain verification of employment and certification from the RN Director or Supervisor that the applicant has demonstrated required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
Please complete Parts II III and IV on page two of this form and return it to the applicant in a sealed business envelope Indicate on the outside of the envelope ldquoEmployment Verification Enclosed ndash Do Not Openrdquo It is the applicantrsquos responsibility to collect the Employment Verification Form(s) and submit them with the application for licensure
Part II Indicate the name and type of facility where the experience was obtained Part III Provide the specific dates that the applicant worked under your supervision in the area of
nursing being verified Additionally indicate if the applicant was employed full time (40 hrswk) or part time and include the number of hours worked in each area The Board MUST receive a breakdown of the number of hours spent in each area in order to evaluate the experience
Part IV Indicate whether the applicant has satisfactorily demonstrated each of the knowledge and skills with safety to the patient The skills listed in Part IV(B) may be demonstrated in classroom lab andor patient care settings
Thank you for your assistance Please feel free to contact the Board at (916) 263-7800 if you have any questions
55A-12 (Rev 1007) 1
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
Part I is to be completed by the applicant and submitted to employers for verification of nursing experience The remainder of this form must be completed by the RN Director or Supervisor and returned to the applicant by the employer in a sealed business envelope FORMS CONTAINING STRIKEOUTS OR CORRECTIONS WILL NOT BE ACCEPTED (See Page 1 for detailed instructions on how to complete this form)
Part I To be completed by the Applicant (print or type - do not use pencil)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 NAME WHILE EMPLOYED AT THIS FACILITY 5 SOCIAL SECURITY NUMBER
NOT required but may assist employer in locating records
6 DAYTIME TELEPHONE NUMBER
( )_________________________________ Area Code
Part II To be completed by the Employer - Indicate the name and type of facility where the experience was obtained
Name of facility where experience was obtained
Type of facility Acute or sub-acute(hospital) Home Health
Convalescent Skilled NursingLong Term Care Outpatient Clinicemergency care Other
Assisted Living
Part III To be completed by the Employer - Include dates and the area of nursing being verified Indicate if employment was full-time (40 hrswk) or part-time and include the total number of hours worked in each area
Areas of Bedside Nursing Experience Employment Period (MonthDateYear) Hours Worked
Per Week Total Hours In Each Area
For Office Use Only
Medical-Surgical Nursing From To Pediatric Nursing From To Maternity Nursing From To Genitourinary Nursing From To Psychiatric Nursing From To Office Nursing From To Long Term CareConvalescent From To Private Duty (in a general acute care facility) From To Other From To
Part IV To be completed by the Employer - Indicate if the applicant has satisfactorily demonstrated the following knowledge and skills with safety to the patient
Knowledge and Skills Demonstrated Knowledge and Skills Demonstrated YES NO YES NO
A Basic Bedside Nursing 1 Ambulation Techniques 9 Intake and Output 2 Bedmaking 10 Personal Hygiene and Comfort Measures 3 Urinary Catheter Care 11 Positioning and Transfer 4 Collection of Specimens 12 Range of Motion 5 Diabetic Testing 13 Skin Care 6 Administration of a Cleansing Enema 14 Vital Signs 7 Feeding Patient 15 Communication Skills Both Verbal and
Written Including Communication With Patients Who Have Psychological Disorders
8 Hot and Cold Applications
B Infection Control Procedures (may be demonstrated in classroom lab andor patient care settings) 1 Asepsis 2 Techniques for strict contact respiratory
enteric tuberculosis drainage universal and immunosuppressed patient isolation
TO BE SIGNED BY THE RN DIRECTOR OR SUPERVISOR I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
Signature ___________________________________________ Print Name___________________________________ Nursing License ___________________Exp Date__________ Telephone Number (_____)_ ____________________ Address _____________________________________________ Todayrsquos Date ________________________________ CityState ___________________________ Zip Code_______
55A-12 (Rev 1007) 2 Date Evaluated ____________ Initials ______
55A-6 (1015) - CONTINUED ON REVERSE -
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS RECORD OF CONVICTION
TYPE OR PRINT (USE BLUE OR BLACK INK ONLY) IF MORE SPACE IS NEEDED TO COMPLETE ANY SECTION PLEASE ATTACH ADDITIONAL SHEETS 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APARTMENT NUMBER)
3 CITY STATE ZIP
4 BIRTHDATE (MMDDYYYY) 6 TELEPHONE NUMBERS
CELL (_______) ________________________________________
HOME (_______) ________________________________________
BUSINESS (_______) ________________________________________
5 SOCIAL SECURITY OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER
7 Pursuant to Business and Professions Code Section 480 (c) any false statements included in this application may result in license denial Please carefully read all information contained on the front and back of this form before signing I declare under penalty of perjury under the laws of the State of California that the information provided herein and attachments is true and correct Signature ____________________________________________________________ Date ____________________________________
8 Are you or have you previously been licensed or certified as a psychiatric technician practical vocational or registered nurse or any other healthcare professional in this or any other state territory or country
Yes No
A
State
License Type
License
Expiration Date
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
B Has your license or certification ever been suspended revoked placed on probation or disciplined If Yes you must explain the basis for the disciplinary action and submit a copy of the disciplinary order
Yes No
C Have you used any other names If Yes list all other names used _______________________________________________________________
Yes No
9 Have you ever been convicted of pled guilty to or pled nolo contendere to ANY offense in the United States or a foreign country If YES you must complete item 12 on the back of this form
This includes every citation infraction misdemeanor andor felony excluding traffic violations under $1000 which do not involve alcohol dangerous drugs or controlled substances Convictions that were adjudicated in the juvenile court or convictions under California Health and Safety Code Sections 11357(b) (c) (d) (e) or Section 11360(b) which are two years or older should NOT be reported Convictions that were later dismissed pursuant to section 12034 12034a or 120341 of the California Penal Code or equivalent non-California law MUST be disclosed If you have obtained a dismissal of your conviction(s) pursuant to Penal Code sections 12034 12034(a) or 120341 please submit a certified copy of the court order dismissing the conviction(s) with your application
Yes No
10 Exclusive of juvenile court adjudications and criminal charges dismissed under section 10003 of the California Penal Code or equivalent non-California laws or convictions two years or older under California Health and Safety Code Sections 11357(b) (c) (d) (e) or section 11360(b) have you had a conviction that was set aside or later expunged from the records of the court If YES you must complete item 12 on the back of this form
Yes No
11 Is any court action pending against you or are you currently awaiting judgment and sentencing following entry of a plea or jury verdict If YES you must complete item 12 on the back of this form
Yes No
Important note You will be permitted to take the licensing examination regardless of any criminal conviction history you disclose However a determination as to whether your license will be granted or denied will not be made until you have passed the examination and the board has received all required conviction documentation
12 If you answered yes to item 9 10 or 11 you must provide all of the information requested below for each offense Department of Motor Vehicles printouts are not accepted in lieu of completing this section If more space is needed to complete this section please attach additional sheets
If you have been convicted of a crime you must submit certified court documents police reports and a detailed explanation in your own words for each offense (Certified courtpolice documents are obtained directly from the courtpolice department with an original stamp of certification Do not send copies as they will not contain an original certification and will not meet the requirement for certified documents If the police report andor court documents are no longer available you must obtain a statement from the police department or court attesting to that fact) Additionally please submit documents regarding your rehabilitation efforts such as
Proof that you complied with the terms of your parole probation restitution or any other court imposed sanctions Evidence of expungement proceedings pursuant to penal code section 12034 12034(a) or 120341 Any other evidence of rehabilitation you wish the board to consider
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
Notice on Collection of Personal Information For Applicants and Licensees
Collection and Use of Personal Information The Board of Vocational Nursing and Psychiatric Technicians (BVNPT) of the Department of Consumer Affairs (DCA) collects the personal information requested on this form as authorized by Business and Professions Code Section 30 (General Provisions) Business and Professions Code Division 2 Chapter 65 Articles 1 amp 2 (Vocational Nursing Practice Act) and Chapter 10 Articles 1 amp 2 (Psychiatric Technicians Law) and California Code of Regulations Title 16 Division 25 Chapter 1 (Vocational Nurses) and Chapter 2 (Psychiatric Technicians) The BVNPT uses this information principally to identify and evaluate applicants for licensure issue and renew licenses and enforce licensing standards set by law and regulation
Mandatory Submission Submission of the requested information is mandatory The BVNPT cannot consider your application for licensure or renewal unless you provide all of the requested information
Access to Personal Information You may review the records maintained by the BVNPT that contain your personal information as permitted by the Information Practices Act See below for contact information
Possible Disclosure of Personal Information The BVNPT makes every effort to protect the personal information you provide The information you provide however may be disclosed in the following circumstances
In response to a Public Records Act request (Government Code Section 6250 and following) as allowed by the Information Practices Act (Civil Code Section 1798 and following)
To another government agency as required or permitted by state or federal law or
In response to a court or administrative order a subpoena or a search warrant
Contact Information For questions about this notice or access to your records you may contact the BVNPT at 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833 (916) 263-7800 or email bvnptdcacagov
55P-1 (42109)
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
APPLICATION FOR VOCATIONAL NURSE LICENSURE
(ATTACH $150 APPLICATION FEE AN ADDITIONAL $49 FINGERPRINT FEE IS REQUIRED FOR PROCESSING ldquoHARD CARDrdquo FINGERPRINTS ndash SEE ENCLOSED INSTRUCTIONS )
Read all the enclosed instructions carefully before completing this application This information is required under Business and Professions Code Division 2 Chapter 65 Articles 1 and 2 The information you furnish will be used to determine your eligibility for licensure If additional space is needed to complete any section of this application please attach additional sheets The Executive Officer of the Board is responsible for information maintenance
PRINT OR TYPE (DO NOT USE PENCIL)
DO NOT WRITE IN THIS SPACE
APP NO
LIC NO
ILF-CA NO
ATS NO
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (MonthDayYear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBER Business (____)_________________________ Home (_____)_________________________
Area Code
7 DID YOU GRADUATE FROM HIGH SCHOOL YES NO NAME OF HIGH SCHOOL_______________________________ CITYSTATE_________________
DID YOU PASS A HIGH SCHOOL EQUIVALENCY TEST YES NO IF NO CIRCLE THE HIGHEST GRADE YOUCOMPLETED 1 2 3 4 5 6 7 8 9 10 11 12
8 DID YOU ATTEND A VOCATIONALPRACTICAL NURSING PROGRAM YES NO DID YOU GRADUATE FROM THE PROGRAM YES NO IF YES NAME OF VOCATIONALPRACTICAL NURSING PROGRAM DATE STARTED DATE COMPLETED STATE OR COUNTRY
_________________________________________________________ ________________ __________________ ___________________
9 DID YOU ATTEND A REGISTERED NURSING PROGRAM YES NO DID YOU GRADUATE FROM THE PROGRAM YES NO IF YES NAME OF REGISTERED NURSING PROGRAM DATE STARTED DATE COMPLETED STATE OR COUNTRY
_________________________________________________________ ________________ __________________ ________________
10 HAVE YOU EVER BEEN LICENSED AS A VOCATIONALPRACTICAL NURSE YES NO DATE LICENSED___________ STATE OF ORIGINAL LICENSE______
IF YES HAS THIS LICENSE EVER BEEN SUSPENDED REVOKED OR PLACED ON PROBATION YES NO (IF YES ATTACH EXPLANATION)
11 HAVE YOU EVER BEEN LICENSED AS A REGISTERED NURSE YES NO DATE LICENSED____________STATE OF ORIGINAL LICENSE____________
IF YES HAS THIS LICENSE EVER BEEN SUSPENDED REVOKED OR PLACED ON PROBATION YES NO (IF YES ATTACH EXPLANATION)
12 HAVE YOU EVER APPLIED TO THIS BOARD FOR LICENSURE UNDER A DIFFERENT NAME YES NO IF ldquoYESrdquo PLEASE LIST OTHER NAMES
WILL DOCUMENTS BE SUBMITTED TO THIS BOARD UNDER A DIFFERENT NAME YES NO IF YES PLEASE LIST OTHER NAMES
13 CONFIDENTIALITY NOTICE YOU ARE ADVISED THAT PURSUANT TO BUSINESS AND PROFESSIONS CODE SECTION 123 THE CONTENT OF THE VOCATIONAL NURSE LICENSURE EXAMINATION IS CONFIDENTIAL IF YOU ARE DEEMED ELIGIBLE TO TAKE THIS EXAMINATION YOU ARE HEREBY NOTIFIED THAT UNAUTHORIZED POSSESSION REPRODUCTION OR DISCLOSURE OF ANY EXAMINATION MATERIALS IS IN VIOLATION OF THE LAW AND SUBJECT TO CRIMINAL MISDEMEANOR PROSECUTION A VIOLAT ION OF THIS TYPE MAY ALSO RESULT IN CIVIL LIABILITY ANDOR DISCIPLINE BY THE LICENSING AGENCY INCLUDING THE DENIAL OF LICENSURE
14 PHOTOGRAPH REQUIREMENTS YOU MUST ATTACH A CURRENT FRONT VIEW HEAD AND SHOULDER PHOTOGRAPH OF YOURSELF IN A SEALED ENVELOPE THE PHOTOGRAPH SHOULD BE 2rdquo X 2rdquo AND MUST BE SIGNED ON THE BACK
15 PLEASE READ CAREFULLY BEFORE SIGNING ndash I hereby certify under penalty of perjury under the laws of the State of California that
the foregoing including any attachments is true and correct False statements included in this application can result in licensure denial
SIGNATURE_____________________________________________________________________ DATE___________ _____________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your Social Security Number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [(42 USCA (c ) (2) (C))] authorizes collection of your Social Security Number Your Social Security Number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your Social Security Number your application for initial license will not be processed and you will be reported to the Franchise Tax Board which may assess a $100 penalty against you
55A-1 (0312)
____
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
RECORD OF NURSING PROGRAM The applicant should complete the first section of this form and provide it to the Director of the nursing program The Director of the nursing program should complete the information in the second section and return it to the above address
THIS SECTION TO BE COMPLETED BY APPLICANT (ITEMS 1-6) PRINT OR TYPE (DO NOT USE PENCIL) 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (MonthDayYear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBERS BUSINESS ( )_________________________________ HOME ( )_________________________________
AREA CODE
THIS SECTION TO BE COMPLETED BY SCHOOLS OF VOCATIONAL PRACTICAL OR REGISTERED NURSING PRINT OR TYPE (DO NOT USE PENCIL)
7 NAME OF SCHOOL OF VOCATIONAL OR PRACTICAL NURSING CITY STATE
______________________________________________________________________ ______________________________________________________
DATE PROGRAM STARTED______________DATE PROGRAM COMPLETED______________ OR DATE VERIFIED HOURS WERE COMPLETED________________
WAS PROGRAM ldquoACCREDITEDrdquo WHEN HOURS WERE COMPLETED YES NO
8 NAME OF SCHOOL OF REGISTERED NURSING CITY STATE
_______________________________________________________________________ _______________________________________________________
DATE PROGRAM STARTED_____________ DATE PROGRAM COMPLETED_______________ OR DATE VERIFIED HOURS WERE COMPLETED________________
WAS PROGRAM ldquoACCREDITEDrdquo WHEN HOURS WERE COMPLETED YES NO
9 COMPLETION OF THE TW ELFTH (12TH) GRADE IN HIGH SCHOOL OR ITS EQUIVALENT HAS BEEN PROVEN BY THE APPLICANT AS FOLLOW S
PRESENTED OFFICIAL SCHOOL RECORDS SHOWING COMPLETION OF 12TH GRADE HIGH SCHOOL
PASSED THE ldquoGEDrdquo TEST AT THE 12TH GRADE LEVEL
10 A TOTAL NUMBER OF THEORYCLINICAL HOURS COMPLETED IN YOUR NURSING PROGRAM
THEORY__________HOURS CLINICAL__________HOURS
B TOTAL NUMBER OF THEORYCLINICAL HOURS WHICH YOUR SCHOOL GRANTED CREDIT FOR ldquoPREVIOUS EDUCATIONrdquo
THEORY__________HOURS CLINICAL__________HOURS
C COMPLETE THE SECOND PAGE OF THIS FORM IN FULL THIS IS A MANDATORY REQUIREMENT
11 I CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
SIGNATURE OF PROGRAM DIRECTOR_____________________________________________
(SCHOOL SEAL) PRINT PROGRAM DIRECTORrsquoS NAME_____________________________________________
DATE________________________________________________________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your social security number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [(42 USCA (c)(2)(C))] authorizes collection of your social security number Your social security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your social security number your application for initial license will not be processed and you will be reported to the Franchise Tax Board
55A-2 (208)
RECORD OF NURSING PROGRAM THIS SECTION OF THE FORM MUST BE COMPLETED IN FULL
1 NAME OF SCHOOL OF NURSING
___________________________________________________________
CHECK ONE
VOCATIONALPRACTICAL NURSING PROGRAM
REGISTERED NURSING PROGRAM
2 CITY 3 STATE AND COUNTRY
4 DATE PROGRAM STARTED ____________________________________
(MONTHDAYYEAR)
5 DATE VERIFIED HOURS WERE COMPLETED____________________________
(MONTHDAYYEAR)
6 SUBJECT ACTUAL HOURSUNITS COMPLETED CHECK HERE
IF SUBJECT IS
INTEGRATED
GRADE RECEIVED HOURSUNITS OF CREDIT GRANTED FOR PREVIOUS
LEARNING
THEORY CLINICAL THEORY CLINICAL THEORY CLINICAL
ANATOMY amp PHYSIOLOGY NA NA NA
NUTRITION NA NA NA
PHARMACOLOGY NA NA NA
PSYCHOLOGY NA NA NA
NORMAL GROWTH amp DEVELOPMENT
NA NA NA
NURSING FUNDAMENTALS
NURSING PROCESS
MEDICAL SURGICAL NURSING
COMMUNICABLE DISEASES
MATERNITY NURSING
PEDIATRIC NURSING
GERONTOLOGICAL NURSING
REHABILITATION NURSING
LEADERSHIP NA NA NA
SUPERVISION NA NA NA
COMMUNICATION NA NA NA
PATIENT EDUCATION NA NA NA
ETHICS amp UNETHICAL CONDUCT NA NA NA
CRITICAL THINKING NA NA NA
CULTURALLY CONGRUENT CARE
END OF LIFE CARE
TOTAL HOURS
____
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
RECORD OF NURSING EXPERIENCE PRINT OR TYPE (DO NOT USE PENCIL)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (monthdayyear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBERS BUSINESS ( )_________________________________ HOME ( )_________________________________
AREA CODE
EXPERIENCE List all nursing experience for the past ten (10) years for which you will be submitting verification of employment It is your responsibility to contact each employer and provide them with a copy of the Employment Verification ndash Nursing Experience Form for completion
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
_________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7B Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From _________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From _________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
NOTE IF MORE SPACE IS NEEDED PLEASE COMPLETE THE SECOND PAGE OF THIS FORM PLEASE READ CAREFULLY BEFORE SIGNING ndash I hereby certify under penalty of perjury under the laws of the State of California that the information
herein including any attachments is true and correct False statements included in this application can result in licensure denial
SIGNATURE_____________________________________________________________________ DATE________________________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your social security number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [42 USCA (c)(2)(C)] authorizes collection of your social security number Your social security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your social security number your application for initial license will not be processed and you will be reported to the Franchise Tax Board which may assess a $100 penalty against you
55A-3(408) 1
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
__________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7E Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7F Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7G Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7H Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7I Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
2
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROW N JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
In order to receive credit for nursing experience State law requires that the Board obtain verification of employment and certification from the Registered Nurse (RN) Director or Supervisor that the applicant has demonstrated the required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
INSTRUCTIONS TO APPLICANT
Complete Part I on the second page of this form and provide a copy of both pages to each employer for the past ten (10) years (You may reproduce as many copies of this form as needed)
This form must be completed in full by the RN Director or Supervisor and returned directly to you in the employerrsquos sealed business envelope The UNOPENED sealed envelopes containing the Employment Verification Forms must be submitted to the Board with your Application for Vocational Nurse Licensure
If you already have an application on the file with the Board and are submitting additional experience the employment verification form may be submitted to the Board by the applicant or the employer but must be received in the employerrsquos sealed business envelope
Please be advised that employment verification forms that appear to have been opened or altered will not be accepted The Board conducts random audits to verify the accuracy of the information submitted Discrepancies or false statements included in the application can result in licensure denial
INSTRUCTIONS TO EMPLOYER
The applicant on page two of this form is applying for licensure as a vocational nurse under Section 2873 of the Business and Professions Code In order for the applicant to receive credit for nursing experience State law requires the Board to obtain verification of employment and certification from the RN Director or Supervisor that the applicant has demonstrated required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
Please complete Parts II III and IV on page two of this form and return it to the applicant in a sealed business envelope Indicate on the outside of the envelope ldquoEmployment Verification Enclosed ndash Do Not Openrdquo It is the applicantrsquos responsibility to collect the Employment Verification Form(s) and submit them with the application for licensure
Part II Indicate the name and type of facility where the experience was obtained Part III Provide the specific dates that the applicant worked under your supervision in the area of
nursing being verified Additionally indicate if the applicant was employed full time (40 hrswk) or part time and include the number of hours worked in each area The Board MUST receive a breakdown of the number of hours spent in each area in order to evaluate the experience
Part IV Indicate whether the applicant has satisfactorily demonstrated each of the knowledge and skills with safety to the patient The skills listed in Part IV(B) may be demonstrated in classroom lab andor patient care settings
Thank you for your assistance Please feel free to contact the Board at (916) 263-7800 if you have any questions
55A-12 (Rev 1007) 1
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
Part I is to be completed by the applicant and submitted to employers for verification of nursing experience The remainder of this form must be completed by the RN Director or Supervisor and returned to the applicant by the employer in a sealed business envelope FORMS CONTAINING STRIKEOUTS OR CORRECTIONS WILL NOT BE ACCEPTED (See Page 1 for detailed instructions on how to complete this form)
Part I To be completed by the Applicant (print or type - do not use pencil)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 NAME WHILE EMPLOYED AT THIS FACILITY 5 SOCIAL SECURITY NUMBER
NOT required but may assist employer in locating records
6 DAYTIME TELEPHONE NUMBER
( )_________________________________ Area Code
Part II To be completed by the Employer - Indicate the name and type of facility where the experience was obtained
Name of facility where experience was obtained
Type of facility Acute or sub-acute(hospital) Home Health
Convalescent Skilled NursingLong Term Care Outpatient Clinicemergency care Other
Assisted Living
Part III To be completed by the Employer - Include dates and the area of nursing being verified Indicate if employment was full-time (40 hrswk) or part-time and include the total number of hours worked in each area
Areas of Bedside Nursing Experience Employment Period (MonthDateYear) Hours Worked
Per Week Total Hours In Each Area
For Office Use Only
Medical-Surgical Nursing From To Pediatric Nursing From To Maternity Nursing From To Genitourinary Nursing From To Psychiatric Nursing From To Office Nursing From To Long Term CareConvalescent From To Private Duty (in a general acute care facility) From To Other From To
Part IV To be completed by the Employer - Indicate if the applicant has satisfactorily demonstrated the following knowledge and skills with safety to the patient
Knowledge and Skills Demonstrated Knowledge and Skills Demonstrated YES NO YES NO
A Basic Bedside Nursing 1 Ambulation Techniques 9 Intake and Output 2 Bedmaking 10 Personal Hygiene and Comfort Measures 3 Urinary Catheter Care 11 Positioning and Transfer 4 Collection of Specimens 12 Range of Motion 5 Diabetic Testing 13 Skin Care 6 Administration of a Cleansing Enema 14 Vital Signs 7 Feeding Patient 15 Communication Skills Both Verbal and
Written Including Communication With Patients Who Have Psychological Disorders
8 Hot and Cold Applications
B Infection Control Procedures (may be demonstrated in classroom lab andor patient care settings) 1 Asepsis 2 Techniques for strict contact respiratory
enteric tuberculosis drainage universal and immunosuppressed patient isolation
TO BE SIGNED BY THE RN DIRECTOR OR SUPERVISOR I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
Signature ___________________________________________ Print Name___________________________________ Nursing License ___________________Exp Date__________ Telephone Number (_____)_ ____________________ Address _____________________________________________ Todayrsquos Date ________________________________ CityState ___________________________ Zip Code_______
55A-12 (Rev 1007) 2 Date Evaluated ____________ Initials ______
55A-6 (1015) - CONTINUED ON REVERSE -
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS RECORD OF CONVICTION
TYPE OR PRINT (USE BLUE OR BLACK INK ONLY) IF MORE SPACE IS NEEDED TO COMPLETE ANY SECTION PLEASE ATTACH ADDITIONAL SHEETS 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APARTMENT NUMBER)
3 CITY STATE ZIP
4 BIRTHDATE (MMDDYYYY) 6 TELEPHONE NUMBERS
CELL (_______) ________________________________________
HOME (_______) ________________________________________
BUSINESS (_______) ________________________________________
5 SOCIAL SECURITY OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER
7 Pursuant to Business and Professions Code Section 480 (c) any false statements included in this application may result in license denial Please carefully read all information contained on the front and back of this form before signing I declare under penalty of perjury under the laws of the State of California that the information provided herein and attachments is true and correct Signature ____________________________________________________________ Date ____________________________________
8 Are you or have you previously been licensed or certified as a psychiatric technician practical vocational or registered nurse or any other healthcare professional in this or any other state territory or country
Yes No
A
State
License Type
License
Expiration Date
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
B Has your license or certification ever been suspended revoked placed on probation or disciplined If Yes you must explain the basis for the disciplinary action and submit a copy of the disciplinary order
Yes No
C Have you used any other names If Yes list all other names used _______________________________________________________________
Yes No
9 Have you ever been convicted of pled guilty to or pled nolo contendere to ANY offense in the United States or a foreign country If YES you must complete item 12 on the back of this form
This includes every citation infraction misdemeanor andor felony excluding traffic violations under $1000 which do not involve alcohol dangerous drugs or controlled substances Convictions that were adjudicated in the juvenile court or convictions under California Health and Safety Code Sections 11357(b) (c) (d) (e) or Section 11360(b) which are two years or older should NOT be reported Convictions that were later dismissed pursuant to section 12034 12034a or 120341 of the California Penal Code or equivalent non-California law MUST be disclosed If you have obtained a dismissal of your conviction(s) pursuant to Penal Code sections 12034 12034(a) or 120341 please submit a certified copy of the court order dismissing the conviction(s) with your application
Yes No
10 Exclusive of juvenile court adjudications and criminal charges dismissed under section 10003 of the California Penal Code or equivalent non-California laws or convictions two years or older under California Health and Safety Code Sections 11357(b) (c) (d) (e) or section 11360(b) have you had a conviction that was set aside or later expunged from the records of the court If YES you must complete item 12 on the back of this form
Yes No
11 Is any court action pending against you or are you currently awaiting judgment and sentencing following entry of a plea or jury verdict If YES you must complete item 12 on the back of this form
Yes No
Important note You will be permitted to take the licensing examination regardless of any criminal conviction history you disclose However a determination as to whether your license will be granted or denied will not be made until you have passed the examination and the board has received all required conviction documentation
12 If you answered yes to item 9 10 or 11 you must provide all of the information requested below for each offense Department of Motor Vehicles printouts are not accepted in lieu of completing this section If more space is needed to complete this section please attach additional sheets
If you have been convicted of a crime you must submit certified court documents police reports and a detailed explanation in your own words for each offense (Certified courtpolice documents are obtained directly from the courtpolice department with an original stamp of certification Do not send copies as they will not contain an original certification and will not meet the requirement for certified documents If the police report andor court documents are no longer available you must obtain a statement from the police department or court attesting to that fact) Additionally please submit documents regarding your rehabilitation efforts such as
Proof that you complied with the terms of your parole probation restitution or any other court imposed sanctions Evidence of expungement proceedings pursuant to penal code section 12034 12034(a) or 120341 Any other evidence of rehabilitation you wish the board to consider
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
Notice on Collection of Personal Information For Applicants and Licensees
Collection and Use of Personal Information The Board of Vocational Nursing and Psychiatric Technicians (BVNPT) of the Department of Consumer Affairs (DCA) collects the personal information requested on this form as authorized by Business and Professions Code Section 30 (General Provisions) Business and Professions Code Division 2 Chapter 65 Articles 1 amp 2 (Vocational Nursing Practice Act) and Chapter 10 Articles 1 amp 2 (Psychiatric Technicians Law) and California Code of Regulations Title 16 Division 25 Chapter 1 (Vocational Nurses) and Chapter 2 (Psychiatric Technicians) The BVNPT uses this information principally to identify and evaluate applicants for licensure issue and renew licenses and enforce licensing standards set by law and regulation
Mandatory Submission Submission of the requested information is mandatory The BVNPT cannot consider your application for licensure or renewal unless you provide all of the requested information
Access to Personal Information You may review the records maintained by the BVNPT that contain your personal information as permitted by the Information Practices Act See below for contact information
Possible Disclosure of Personal Information The BVNPT makes every effort to protect the personal information you provide The information you provide however may be disclosed in the following circumstances
In response to a Public Records Act request (Government Code Section 6250 and following) as allowed by the Information Practices Act (Civil Code Section 1798 and following)
To another government agency as required or permitted by state or federal law or
In response to a court or administrative order a subpoena or a search warrant
Contact Information For questions about this notice or access to your records you may contact the BVNPT at 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833 (916) 263-7800 or email bvnptdcacagov
55P-1 (42109)
____
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
RECORD OF NURSING PROGRAM The applicant should complete the first section of this form and provide it to the Director of the nursing program The Director of the nursing program should complete the information in the second section and return it to the above address
THIS SECTION TO BE COMPLETED BY APPLICANT (ITEMS 1-6) PRINT OR TYPE (DO NOT USE PENCIL) 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (MonthDayYear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBERS BUSINESS ( )_________________________________ HOME ( )_________________________________
AREA CODE
THIS SECTION TO BE COMPLETED BY SCHOOLS OF VOCATIONAL PRACTICAL OR REGISTERED NURSING PRINT OR TYPE (DO NOT USE PENCIL)
7 NAME OF SCHOOL OF VOCATIONAL OR PRACTICAL NURSING CITY STATE
______________________________________________________________________ ______________________________________________________
DATE PROGRAM STARTED______________DATE PROGRAM COMPLETED______________ OR DATE VERIFIED HOURS WERE COMPLETED________________
WAS PROGRAM ldquoACCREDITEDrdquo WHEN HOURS WERE COMPLETED YES NO
8 NAME OF SCHOOL OF REGISTERED NURSING CITY STATE
_______________________________________________________________________ _______________________________________________________
DATE PROGRAM STARTED_____________ DATE PROGRAM COMPLETED_______________ OR DATE VERIFIED HOURS WERE COMPLETED________________
WAS PROGRAM ldquoACCREDITEDrdquo WHEN HOURS WERE COMPLETED YES NO
9 COMPLETION OF THE TW ELFTH (12TH) GRADE IN HIGH SCHOOL OR ITS EQUIVALENT HAS BEEN PROVEN BY THE APPLICANT AS FOLLOW S
PRESENTED OFFICIAL SCHOOL RECORDS SHOWING COMPLETION OF 12TH GRADE HIGH SCHOOL
PASSED THE ldquoGEDrdquo TEST AT THE 12TH GRADE LEVEL
10 A TOTAL NUMBER OF THEORYCLINICAL HOURS COMPLETED IN YOUR NURSING PROGRAM
THEORY__________HOURS CLINICAL__________HOURS
B TOTAL NUMBER OF THEORYCLINICAL HOURS WHICH YOUR SCHOOL GRANTED CREDIT FOR ldquoPREVIOUS EDUCATIONrdquo
THEORY__________HOURS CLINICAL__________HOURS
C COMPLETE THE SECOND PAGE OF THIS FORM IN FULL THIS IS A MANDATORY REQUIREMENT
11 I CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
SIGNATURE OF PROGRAM DIRECTOR_____________________________________________
(SCHOOL SEAL) PRINT PROGRAM DIRECTORrsquoS NAME_____________________________________________
DATE________________________________________________________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your social security number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [(42 USCA (c)(2)(C))] authorizes collection of your social security number Your social security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your social security number your application for initial license will not be processed and you will be reported to the Franchise Tax Board
55A-2 (208)
RECORD OF NURSING PROGRAM THIS SECTION OF THE FORM MUST BE COMPLETED IN FULL
1 NAME OF SCHOOL OF NURSING
___________________________________________________________
CHECK ONE
VOCATIONALPRACTICAL NURSING PROGRAM
REGISTERED NURSING PROGRAM
2 CITY 3 STATE AND COUNTRY
4 DATE PROGRAM STARTED ____________________________________
(MONTHDAYYEAR)
5 DATE VERIFIED HOURS WERE COMPLETED____________________________
(MONTHDAYYEAR)
6 SUBJECT ACTUAL HOURSUNITS COMPLETED CHECK HERE
IF SUBJECT IS
INTEGRATED
GRADE RECEIVED HOURSUNITS OF CREDIT GRANTED FOR PREVIOUS
LEARNING
THEORY CLINICAL THEORY CLINICAL THEORY CLINICAL
ANATOMY amp PHYSIOLOGY NA NA NA
NUTRITION NA NA NA
PHARMACOLOGY NA NA NA
PSYCHOLOGY NA NA NA
NORMAL GROWTH amp DEVELOPMENT
NA NA NA
NURSING FUNDAMENTALS
NURSING PROCESS
MEDICAL SURGICAL NURSING
COMMUNICABLE DISEASES
MATERNITY NURSING
PEDIATRIC NURSING
GERONTOLOGICAL NURSING
REHABILITATION NURSING
LEADERSHIP NA NA NA
SUPERVISION NA NA NA
COMMUNICATION NA NA NA
PATIENT EDUCATION NA NA NA
ETHICS amp UNETHICAL CONDUCT NA NA NA
CRITICAL THINKING NA NA NA
CULTURALLY CONGRUENT CARE
END OF LIFE CARE
TOTAL HOURS
____
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
RECORD OF NURSING EXPERIENCE PRINT OR TYPE (DO NOT USE PENCIL)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (monthdayyear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBERS BUSINESS ( )_________________________________ HOME ( )_________________________________
AREA CODE
EXPERIENCE List all nursing experience for the past ten (10) years for which you will be submitting verification of employment It is your responsibility to contact each employer and provide them with a copy of the Employment Verification ndash Nursing Experience Form for completion
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
_________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7B Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From _________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From _________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
NOTE IF MORE SPACE IS NEEDED PLEASE COMPLETE THE SECOND PAGE OF THIS FORM PLEASE READ CAREFULLY BEFORE SIGNING ndash I hereby certify under penalty of perjury under the laws of the State of California that the information
herein including any attachments is true and correct False statements included in this application can result in licensure denial
SIGNATURE_____________________________________________________________________ DATE________________________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your social security number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [42 USCA (c)(2)(C)] authorizes collection of your social security number Your social security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your social security number your application for initial license will not be processed and you will be reported to the Franchise Tax Board which may assess a $100 penalty against you
55A-3(408) 1
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
__________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7E Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7F Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7G Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7H Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7I Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
2
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROW N JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
In order to receive credit for nursing experience State law requires that the Board obtain verification of employment and certification from the Registered Nurse (RN) Director or Supervisor that the applicant has demonstrated the required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
INSTRUCTIONS TO APPLICANT
Complete Part I on the second page of this form and provide a copy of both pages to each employer for the past ten (10) years (You may reproduce as many copies of this form as needed)
This form must be completed in full by the RN Director or Supervisor and returned directly to you in the employerrsquos sealed business envelope The UNOPENED sealed envelopes containing the Employment Verification Forms must be submitted to the Board with your Application for Vocational Nurse Licensure
If you already have an application on the file with the Board and are submitting additional experience the employment verification form may be submitted to the Board by the applicant or the employer but must be received in the employerrsquos sealed business envelope
Please be advised that employment verification forms that appear to have been opened or altered will not be accepted The Board conducts random audits to verify the accuracy of the information submitted Discrepancies or false statements included in the application can result in licensure denial
INSTRUCTIONS TO EMPLOYER
The applicant on page two of this form is applying for licensure as a vocational nurse under Section 2873 of the Business and Professions Code In order for the applicant to receive credit for nursing experience State law requires the Board to obtain verification of employment and certification from the RN Director or Supervisor that the applicant has demonstrated required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
Please complete Parts II III and IV on page two of this form and return it to the applicant in a sealed business envelope Indicate on the outside of the envelope ldquoEmployment Verification Enclosed ndash Do Not Openrdquo It is the applicantrsquos responsibility to collect the Employment Verification Form(s) and submit them with the application for licensure
Part II Indicate the name and type of facility where the experience was obtained Part III Provide the specific dates that the applicant worked under your supervision in the area of
nursing being verified Additionally indicate if the applicant was employed full time (40 hrswk) or part time and include the number of hours worked in each area The Board MUST receive a breakdown of the number of hours spent in each area in order to evaluate the experience
Part IV Indicate whether the applicant has satisfactorily demonstrated each of the knowledge and skills with safety to the patient The skills listed in Part IV(B) may be demonstrated in classroom lab andor patient care settings
Thank you for your assistance Please feel free to contact the Board at (916) 263-7800 if you have any questions
55A-12 (Rev 1007) 1
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
Part I is to be completed by the applicant and submitted to employers for verification of nursing experience The remainder of this form must be completed by the RN Director or Supervisor and returned to the applicant by the employer in a sealed business envelope FORMS CONTAINING STRIKEOUTS OR CORRECTIONS WILL NOT BE ACCEPTED (See Page 1 for detailed instructions on how to complete this form)
Part I To be completed by the Applicant (print or type - do not use pencil)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 NAME WHILE EMPLOYED AT THIS FACILITY 5 SOCIAL SECURITY NUMBER
NOT required but may assist employer in locating records
6 DAYTIME TELEPHONE NUMBER
( )_________________________________ Area Code
Part II To be completed by the Employer - Indicate the name and type of facility where the experience was obtained
Name of facility where experience was obtained
Type of facility Acute or sub-acute(hospital) Home Health
Convalescent Skilled NursingLong Term Care Outpatient Clinicemergency care Other
Assisted Living
Part III To be completed by the Employer - Include dates and the area of nursing being verified Indicate if employment was full-time (40 hrswk) or part-time and include the total number of hours worked in each area
Areas of Bedside Nursing Experience Employment Period (MonthDateYear) Hours Worked
Per Week Total Hours In Each Area
For Office Use Only
Medical-Surgical Nursing From To Pediatric Nursing From To Maternity Nursing From To Genitourinary Nursing From To Psychiatric Nursing From To Office Nursing From To Long Term CareConvalescent From To Private Duty (in a general acute care facility) From To Other From To
Part IV To be completed by the Employer - Indicate if the applicant has satisfactorily demonstrated the following knowledge and skills with safety to the patient
Knowledge and Skills Demonstrated Knowledge and Skills Demonstrated YES NO YES NO
A Basic Bedside Nursing 1 Ambulation Techniques 9 Intake and Output 2 Bedmaking 10 Personal Hygiene and Comfort Measures 3 Urinary Catheter Care 11 Positioning and Transfer 4 Collection of Specimens 12 Range of Motion 5 Diabetic Testing 13 Skin Care 6 Administration of a Cleansing Enema 14 Vital Signs 7 Feeding Patient 15 Communication Skills Both Verbal and
Written Including Communication With Patients Who Have Psychological Disorders
8 Hot and Cold Applications
B Infection Control Procedures (may be demonstrated in classroom lab andor patient care settings) 1 Asepsis 2 Techniques for strict contact respiratory
enteric tuberculosis drainage universal and immunosuppressed patient isolation
TO BE SIGNED BY THE RN DIRECTOR OR SUPERVISOR I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
Signature ___________________________________________ Print Name___________________________________ Nursing License ___________________Exp Date__________ Telephone Number (_____)_ ____________________ Address _____________________________________________ Todayrsquos Date ________________________________ CityState ___________________________ Zip Code_______
55A-12 (Rev 1007) 2 Date Evaluated ____________ Initials ______
55A-6 (1015) - CONTINUED ON REVERSE -
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS RECORD OF CONVICTION
TYPE OR PRINT (USE BLUE OR BLACK INK ONLY) IF MORE SPACE IS NEEDED TO COMPLETE ANY SECTION PLEASE ATTACH ADDITIONAL SHEETS 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APARTMENT NUMBER)
3 CITY STATE ZIP
4 BIRTHDATE (MMDDYYYY) 6 TELEPHONE NUMBERS
CELL (_______) ________________________________________
HOME (_______) ________________________________________
BUSINESS (_______) ________________________________________
5 SOCIAL SECURITY OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER
7 Pursuant to Business and Professions Code Section 480 (c) any false statements included in this application may result in license denial Please carefully read all information contained on the front and back of this form before signing I declare under penalty of perjury under the laws of the State of California that the information provided herein and attachments is true and correct Signature ____________________________________________________________ Date ____________________________________
8 Are you or have you previously been licensed or certified as a psychiatric technician practical vocational or registered nurse or any other healthcare professional in this or any other state territory or country
Yes No
A
State
License Type
License
Expiration Date
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
B Has your license or certification ever been suspended revoked placed on probation or disciplined If Yes you must explain the basis for the disciplinary action and submit a copy of the disciplinary order
Yes No
C Have you used any other names If Yes list all other names used _______________________________________________________________
Yes No
9 Have you ever been convicted of pled guilty to or pled nolo contendere to ANY offense in the United States or a foreign country If YES you must complete item 12 on the back of this form
This includes every citation infraction misdemeanor andor felony excluding traffic violations under $1000 which do not involve alcohol dangerous drugs or controlled substances Convictions that were adjudicated in the juvenile court or convictions under California Health and Safety Code Sections 11357(b) (c) (d) (e) or Section 11360(b) which are two years or older should NOT be reported Convictions that were later dismissed pursuant to section 12034 12034a or 120341 of the California Penal Code or equivalent non-California law MUST be disclosed If you have obtained a dismissal of your conviction(s) pursuant to Penal Code sections 12034 12034(a) or 120341 please submit a certified copy of the court order dismissing the conviction(s) with your application
Yes No
10 Exclusive of juvenile court adjudications and criminal charges dismissed under section 10003 of the California Penal Code or equivalent non-California laws or convictions two years or older under California Health and Safety Code Sections 11357(b) (c) (d) (e) or section 11360(b) have you had a conviction that was set aside or later expunged from the records of the court If YES you must complete item 12 on the back of this form
Yes No
11 Is any court action pending against you or are you currently awaiting judgment and sentencing following entry of a plea or jury verdict If YES you must complete item 12 on the back of this form
Yes No
Important note You will be permitted to take the licensing examination regardless of any criminal conviction history you disclose However a determination as to whether your license will be granted or denied will not be made until you have passed the examination and the board has received all required conviction documentation
12 If you answered yes to item 9 10 or 11 you must provide all of the information requested below for each offense Department of Motor Vehicles printouts are not accepted in lieu of completing this section If more space is needed to complete this section please attach additional sheets
If you have been convicted of a crime you must submit certified court documents police reports and a detailed explanation in your own words for each offense (Certified courtpolice documents are obtained directly from the courtpolice department with an original stamp of certification Do not send copies as they will not contain an original certification and will not meet the requirement for certified documents If the police report andor court documents are no longer available you must obtain a statement from the police department or court attesting to that fact) Additionally please submit documents regarding your rehabilitation efforts such as
Proof that you complied with the terms of your parole probation restitution or any other court imposed sanctions Evidence of expungement proceedings pursuant to penal code section 12034 12034(a) or 120341 Any other evidence of rehabilitation you wish the board to consider
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
Notice on Collection of Personal Information For Applicants and Licensees
Collection and Use of Personal Information The Board of Vocational Nursing and Psychiatric Technicians (BVNPT) of the Department of Consumer Affairs (DCA) collects the personal information requested on this form as authorized by Business and Professions Code Section 30 (General Provisions) Business and Professions Code Division 2 Chapter 65 Articles 1 amp 2 (Vocational Nursing Practice Act) and Chapter 10 Articles 1 amp 2 (Psychiatric Technicians Law) and California Code of Regulations Title 16 Division 25 Chapter 1 (Vocational Nurses) and Chapter 2 (Psychiatric Technicians) The BVNPT uses this information principally to identify and evaluate applicants for licensure issue and renew licenses and enforce licensing standards set by law and regulation
Mandatory Submission Submission of the requested information is mandatory The BVNPT cannot consider your application for licensure or renewal unless you provide all of the requested information
Access to Personal Information You may review the records maintained by the BVNPT that contain your personal information as permitted by the Information Practices Act See below for contact information
Possible Disclosure of Personal Information The BVNPT makes every effort to protect the personal information you provide The information you provide however may be disclosed in the following circumstances
In response to a Public Records Act request (Government Code Section 6250 and following) as allowed by the Information Practices Act (Civil Code Section 1798 and following)
To another government agency as required or permitted by state or federal law or
In response to a court or administrative order a subpoena or a search warrant
Contact Information For questions about this notice or access to your records you may contact the BVNPT at 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833 (916) 263-7800 or email bvnptdcacagov
55P-1 (42109)
RECORD OF NURSING PROGRAM THIS SECTION OF THE FORM MUST BE COMPLETED IN FULL
1 NAME OF SCHOOL OF NURSING
___________________________________________________________
CHECK ONE
VOCATIONALPRACTICAL NURSING PROGRAM
REGISTERED NURSING PROGRAM
2 CITY 3 STATE AND COUNTRY
4 DATE PROGRAM STARTED ____________________________________
(MONTHDAYYEAR)
5 DATE VERIFIED HOURS WERE COMPLETED____________________________
(MONTHDAYYEAR)
6 SUBJECT ACTUAL HOURSUNITS COMPLETED CHECK HERE
IF SUBJECT IS
INTEGRATED
GRADE RECEIVED HOURSUNITS OF CREDIT GRANTED FOR PREVIOUS
LEARNING
THEORY CLINICAL THEORY CLINICAL THEORY CLINICAL
ANATOMY amp PHYSIOLOGY NA NA NA
NUTRITION NA NA NA
PHARMACOLOGY NA NA NA
PSYCHOLOGY NA NA NA
NORMAL GROWTH amp DEVELOPMENT
NA NA NA
NURSING FUNDAMENTALS
NURSING PROCESS
MEDICAL SURGICAL NURSING
COMMUNICABLE DISEASES
MATERNITY NURSING
PEDIATRIC NURSING
GERONTOLOGICAL NURSING
REHABILITATION NURSING
LEADERSHIP NA NA NA
SUPERVISION NA NA NA
COMMUNICATION NA NA NA
PATIENT EDUCATION NA NA NA
ETHICS amp UNETHICAL CONDUCT NA NA NA
CRITICAL THINKING NA NA NA
CULTURALLY CONGRUENT CARE
END OF LIFE CARE
TOTAL HOURS
____
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
RECORD OF NURSING EXPERIENCE PRINT OR TYPE (DO NOT USE PENCIL)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (monthdayyear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBERS BUSINESS ( )_________________________________ HOME ( )_________________________________
AREA CODE
EXPERIENCE List all nursing experience for the past ten (10) years for which you will be submitting verification of employment It is your responsibility to contact each employer and provide them with a copy of the Employment Verification ndash Nursing Experience Form for completion
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
_________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7B Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From _________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From _________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
NOTE IF MORE SPACE IS NEEDED PLEASE COMPLETE THE SECOND PAGE OF THIS FORM PLEASE READ CAREFULLY BEFORE SIGNING ndash I hereby certify under penalty of perjury under the laws of the State of California that the information
herein including any attachments is true and correct False statements included in this application can result in licensure denial
SIGNATURE_____________________________________________________________________ DATE________________________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your social security number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [42 USCA (c)(2)(C)] authorizes collection of your social security number Your social security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your social security number your application for initial license will not be processed and you will be reported to the Franchise Tax Board which may assess a $100 penalty against you
55A-3(408) 1
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
__________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7E Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7F Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7G Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7H Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7I Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
2
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROW N JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
In order to receive credit for nursing experience State law requires that the Board obtain verification of employment and certification from the Registered Nurse (RN) Director or Supervisor that the applicant has demonstrated the required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
INSTRUCTIONS TO APPLICANT
Complete Part I on the second page of this form and provide a copy of both pages to each employer for the past ten (10) years (You may reproduce as many copies of this form as needed)
This form must be completed in full by the RN Director or Supervisor and returned directly to you in the employerrsquos sealed business envelope The UNOPENED sealed envelopes containing the Employment Verification Forms must be submitted to the Board with your Application for Vocational Nurse Licensure
If you already have an application on the file with the Board and are submitting additional experience the employment verification form may be submitted to the Board by the applicant or the employer but must be received in the employerrsquos sealed business envelope
Please be advised that employment verification forms that appear to have been opened or altered will not be accepted The Board conducts random audits to verify the accuracy of the information submitted Discrepancies or false statements included in the application can result in licensure denial
INSTRUCTIONS TO EMPLOYER
The applicant on page two of this form is applying for licensure as a vocational nurse under Section 2873 of the Business and Professions Code In order for the applicant to receive credit for nursing experience State law requires the Board to obtain verification of employment and certification from the RN Director or Supervisor that the applicant has demonstrated required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
Please complete Parts II III and IV on page two of this form and return it to the applicant in a sealed business envelope Indicate on the outside of the envelope ldquoEmployment Verification Enclosed ndash Do Not Openrdquo It is the applicantrsquos responsibility to collect the Employment Verification Form(s) and submit them with the application for licensure
Part II Indicate the name and type of facility where the experience was obtained Part III Provide the specific dates that the applicant worked under your supervision in the area of
nursing being verified Additionally indicate if the applicant was employed full time (40 hrswk) or part time and include the number of hours worked in each area The Board MUST receive a breakdown of the number of hours spent in each area in order to evaluate the experience
Part IV Indicate whether the applicant has satisfactorily demonstrated each of the knowledge and skills with safety to the patient The skills listed in Part IV(B) may be demonstrated in classroom lab andor patient care settings
Thank you for your assistance Please feel free to contact the Board at (916) 263-7800 if you have any questions
55A-12 (Rev 1007) 1
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
Part I is to be completed by the applicant and submitted to employers for verification of nursing experience The remainder of this form must be completed by the RN Director or Supervisor and returned to the applicant by the employer in a sealed business envelope FORMS CONTAINING STRIKEOUTS OR CORRECTIONS WILL NOT BE ACCEPTED (See Page 1 for detailed instructions on how to complete this form)
Part I To be completed by the Applicant (print or type - do not use pencil)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 NAME WHILE EMPLOYED AT THIS FACILITY 5 SOCIAL SECURITY NUMBER
NOT required but may assist employer in locating records
6 DAYTIME TELEPHONE NUMBER
( )_________________________________ Area Code
Part II To be completed by the Employer - Indicate the name and type of facility where the experience was obtained
Name of facility where experience was obtained
Type of facility Acute or sub-acute(hospital) Home Health
Convalescent Skilled NursingLong Term Care Outpatient Clinicemergency care Other
Assisted Living
Part III To be completed by the Employer - Include dates and the area of nursing being verified Indicate if employment was full-time (40 hrswk) or part-time and include the total number of hours worked in each area
Areas of Bedside Nursing Experience Employment Period (MonthDateYear) Hours Worked
Per Week Total Hours In Each Area
For Office Use Only
Medical-Surgical Nursing From To Pediatric Nursing From To Maternity Nursing From To Genitourinary Nursing From To Psychiatric Nursing From To Office Nursing From To Long Term CareConvalescent From To Private Duty (in a general acute care facility) From To Other From To
Part IV To be completed by the Employer - Indicate if the applicant has satisfactorily demonstrated the following knowledge and skills with safety to the patient
Knowledge and Skills Demonstrated Knowledge and Skills Demonstrated YES NO YES NO
A Basic Bedside Nursing 1 Ambulation Techniques 9 Intake and Output 2 Bedmaking 10 Personal Hygiene and Comfort Measures 3 Urinary Catheter Care 11 Positioning and Transfer 4 Collection of Specimens 12 Range of Motion 5 Diabetic Testing 13 Skin Care 6 Administration of a Cleansing Enema 14 Vital Signs 7 Feeding Patient 15 Communication Skills Both Verbal and
Written Including Communication With Patients Who Have Psychological Disorders
8 Hot and Cold Applications
B Infection Control Procedures (may be demonstrated in classroom lab andor patient care settings) 1 Asepsis 2 Techniques for strict contact respiratory
enteric tuberculosis drainage universal and immunosuppressed patient isolation
TO BE SIGNED BY THE RN DIRECTOR OR SUPERVISOR I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
Signature ___________________________________________ Print Name___________________________________ Nursing License ___________________Exp Date__________ Telephone Number (_____)_ ____________________ Address _____________________________________________ Todayrsquos Date ________________________________ CityState ___________________________ Zip Code_______
55A-12 (Rev 1007) 2 Date Evaluated ____________ Initials ______
55A-6 (1015) - CONTINUED ON REVERSE -
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS RECORD OF CONVICTION
TYPE OR PRINT (USE BLUE OR BLACK INK ONLY) IF MORE SPACE IS NEEDED TO COMPLETE ANY SECTION PLEASE ATTACH ADDITIONAL SHEETS 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APARTMENT NUMBER)
3 CITY STATE ZIP
4 BIRTHDATE (MMDDYYYY) 6 TELEPHONE NUMBERS
CELL (_______) ________________________________________
HOME (_______) ________________________________________
BUSINESS (_______) ________________________________________
5 SOCIAL SECURITY OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER
7 Pursuant to Business and Professions Code Section 480 (c) any false statements included in this application may result in license denial Please carefully read all information contained on the front and back of this form before signing I declare under penalty of perjury under the laws of the State of California that the information provided herein and attachments is true and correct Signature ____________________________________________________________ Date ____________________________________
8 Are you or have you previously been licensed or certified as a psychiatric technician practical vocational or registered nurse or any other healthcare professional in this or any other state territory or country
Yes No
A
State
License Type
License
Expiration Date
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
B Has your license or certification ever been suspended revoked placed on probation or disciplined If Yes you must explain the basis for the disciplinary action and submit a copy of the disciplinary order
Yes No
C Have you used any other names If Yes list all other names used _______________________________________________________________
Yes No
9 Have you ever been convicted of pled guilty to or pled nolo contendere to ANY offense in the United States or a foreign country If YES you must complete item 12 on the back of this form
This includes every citation infraction misdemeanor andor felony excluding traffic violations under $1000 which do not involve alcohol dangerous drugs or controlled substances Convictions that were adjudicated in the juvenile court or convictions under California Health and Safety Code Sections 11357(b) (c) (d) (e) or Section 11360(b) which are two years or older should NOT be reported Convictions that were later dismissed pursuant to section 12034 12034a or 120341 of the California Penal Code or equivalent non-California law MUST be disclosed If you have obtained a dismissal of your conviction(s) pursuant to Penal Code sections 12034 12034(a) or 120341 please submit a certified copy of the court order dismissing the conviction(s) with your application
Yes No
10 Exclusive of juvenile court adjudications and criminal charges dismissed under section 10003 of the California Penal Code or equivalent non-California laws or convictions two years or older under California Health and Safety Code Sections 11357(b) (c) (d) (e) or section 11360(b) have you had a conviction that was set aside or later expunged from the records of the court If YES you must complete item 12 on the back of this form
Yes No
11 Is any court action pending against you or are you currently awaiting judgment and sentencing following entry of a plea or jury verdict If YES you must complete item 12 on the back of this form
Yes No
Important note You will be permitted to take the licensing examination regardless of any criminal conviction history you disclose However a determination as to whether your license will be granted or denied will not be made until you have passed the examination and the board has received all required conviction documentation
12 If you answered yes to item 9 10 or 11 you must provide all of the information requested below for each offense Department of Motor Vehicles printouts are not accepted in lieu of completing this section If more space is needed to complete this section please attach additional sheets
If you have been convicted of a crime you must submit certified court documents police reports and a detailed explanation in your own words for each offense (Certified courtpolice documents are obtained directly from the courtpolice department with an original stamp of certification Do not send copies as they will not contain an original certification and will not meet the requirement for certified documents If the police report andor court documents are no longer available you must obtain a statement from the police department or court attesting to that fact) Additionally please submit documents regarding your rehabilitation efforts such as
Proof that you complied with the terms of your parole probation restitution or any other court imposed sanctions Evidence of expungement proceedings pursuant to penal code section 12034 12034(a) or 120341 Any other evidence of rehabilitation you wish the board to consider
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
Notice on Collection of Personal Information For Applicants and Licensees
Collection and Use of Personal Information The Board of Vocational Nursing and Psychiatric Technicians (BVNPT) of the Department of Consumer Affairs (DCA) collects the personal information requested on this form as authorized by Business and Professions Code Section 30 (General Provisions) Business and Professions Code Division 2 Chapter 65 Articles 1 amp 2 (Vocational Nursing Practice Act) and Chapter 10 Articles 1 amp 2 (Psychiatric Technicians Law) and California Code of Regulations Title 16 Division 25 Chapter 1 (Vocational Nurses) and Chapter 2 (Psychiatric Technicians) The BVNPT uses this information principally to identify and evaluate applicants for licensure issue and renew licenses and enforce licensing standards set by law and regulation
Mandatory Submission Submission of the requested information is mandatory The BVNPT cannot consider your application for licensure or renewal unless you provide all of the requested information
Access to Personal Information You may review the records maintained by the BVNPT that contain your personal information as permitted by the Information Practices Act See below for contact information
Possible Disclosure of Personal Information The BVNPT makes every effort to protect the personal information you provide The information you provide however may be disclosed in the following circumstances
In response to a Public Records Act request (Government Code Section 6250 and following) as allowed by the Information Practices Act (Civil Code Section 1798 and following)
To another government agency as required or permitted by state or federal law or
In response to a court or administrative order a subpoena or a search warrant
Contact Information For questions about this notice or access to your records you may contact the BVNPT at 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833 (916) 263-7800 or email bvnptdcacagov
55P-1 (42109)
____
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
RECORD OF NURSING EXPERIENCE PRINT OR TYPE (DO NOT USE PENCIL)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 BIRTHDATE (monthdayyear) 5 SOCIAL SECURITY NUMBER 6 TELEPHONE NUMBERS BUSINESS ( )_________________________________ HOME ( )_________________________________
AREA CODE
EXPERIENCE List all nursing experience for the past ten (10) years for which you will be submitting verification of employment It is your responsibility to contact each employer and provide them with a copy of the Employment Verification ndash Nursing Experience Form for completion
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
_________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7B Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From _________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From _________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
NOTE IF MORE SPACE IS NEEDED PLEASE COMPLETE THE SECOND PAGE OF THIS FORM PLEASE READ CAREFULLY BEFORE SIGNING ndash I hereby certify under penalty of perjury under the laws of the State of California that the information
herein including any attachments is true and correct False statements included in this application can result in licensure denial
SIGNATURE_____________________________________________________________________ DATE________________________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT ndash Disclosure of your social security number is mandatory Section 30 of the Business and Professions Code and Public Law 94-455 [42 USCA (c)(2)(C)] authorizes collection of your social security number Your social security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or order for family support in accordance with Section 17520 of the Family Code or for verification of licensure or examination status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the requesting state If you fail to disclose your social security number your application for initial license will not be processed and you will be reported to the Franchise Tax Board which may assess a $100 penalty against you
55A-3(408) 1
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
__________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7E Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7F Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7G Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7H Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7I Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
2
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROW N JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
In order to receive credit for nursing experience State law requires that the Board obtain verification of employment and certification from the Registered Nurse (RN) Director or Supervisor that the applicant has demonstrated the required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
INSTRUCTIONS TO APPLICANT
Complete Part I on the second page of this form and provide a copy of both pages to each employer for the past ten (10) years (You may reproduce as many copies of this form as needed)
This form must be completed in full by the RN Director or Supervisor and returned directly to you in the employerrsquos sealed business envelope The UNOPENED sealed envelopes containing the Employment Verification Forms must be submitted to the Board with your Application for Vocational Nurse Licensure
If you already have an application on the file with the Board and are submitting additional experience the employment verification form may be submitted to the Board by the applicant or the employer but must be received in the employerrsquos sealed business envelope
Please be advised that employment verification forms that appear to have been opened or altered will not be accepted The Board conducts random audits to verify the accuracy of the information submitted Discrepancies or false statements included in the application can result in licensure denial
INSTRUCTIONS TO EMPLOYER
The applicant on page two of this form is applying for licensure as a vocational nurse under Section 2873 of the Business and Professions Code In order for the applicant to receive credit for nursing experience State law requires the Board to obtain verification of employment and certification from the RN Director or Supervisor that the applicant has demonstrated required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
Please complete Parts II III and IV on page two of this form and return it to the applicant in a sealed business envelope Indicate on the outside of the envelope ldquoEmployment Verification Enclosed ndash Do Not Openrdquo It is the applicantrsquos responsibility to collect the Employment Verification Form(s) and submit them with the application for licensure
Part II Indicate the name and type of facility where the experience was obtained Part III Provide the specific dates that the applicant worked under your supervision in the area of
nursing being verified Additionally indicate if the applicant was employed full time (40 hrswk) or part time and include the number of hours worked in each area The Board MUST receive a breakdown of the number of hours spent in each area in order to evaluate the experience
Part IV Indicate whether the applicant has satisfactorily demonstrated each of the knowledge and skills with safety to the patient The skills listed in Part IV(B) may be demonstrated in classroom lab andor patient care settings
Thank you for your assistance Please feel free to contact the Board at (916) 263-7800 if you have any questions
55A-12 (Rev 1007) 1
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
Part I is to be completed by the applicant and submitted to employers for verification of nursing experience The remainder of this form must be completed by the RN Director or Supervisor and returned to the applicant by the employer in a sealed business envelope FORMS CONTAINING STRIKEOUTS OR CORRECTIONS WILL NOT BE ACCEPTED (See Page 1 for detailed instructions on how to complete this form)
Part I To be completed by the Applicant (print or type - do not use pencil)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 NAME WHILE EMPLOYED AT THIS FACILITY 5 SOCIAL SECURITY NUMBER
NOT required but may assist employer in locating records
6 DAYTIME TELEPHONE NUMBER
( )_________________________________ Area Code
Part II To be completed by the Employer - Indicate the name and type of facility where the experience was obtained
Name of facility where experience was obtained
Type of facility Acute or sub-acute(hospital) Home Health
Convalescent Skilled NursingLong Term Care Outpatient Clinicemergency care Other
Assisted Living
Part III To be completed by the Employer - Include dates and the area of nursing being verified Indicate if employment was full-time (40 hrswk) or part-time and include the total number of hours worked in each area
Areas of Bedside Nursing Experience Employment Period (MonthDateYear) Hours Worked
Per Week Total Hours In Each Area
For Office Use Only
Medical-Surgical Nursing From To Pediatric Nursing From To Maternity Nursing From To Genitourinary Nursing From To Psychiatric Nursing From To Office Nursing From To Long Term CareConvalescent From To Private Duty (in a general acute care facility) From To Other From To
Part IV To be completed by the Employer - Indicate if the applicant has satisfactorily demonstrated the following knowledge and skills with safety to the patient
Knowledge and Skills Demonstrated Knowledge and Skills Demonstrated YES NO YES NO
A Basic Bedside Nursing 1 Ambulation Techniques 9 Intake and Output 2 Bedmaking 10 Personal Hygiene and Comfort Measures 3 Urinary Catheter Care 11 Positioning and Transfer 4 Collection of Specimens 12 Range of Motion 5 Diabetic Testing 13 Skin Care 6 Administration of a Cleansing Enema 14 Vital Signs 7 Feeding Patient 15 Communication Skills Both Verbal and
Written Including Communication With Patients Who Have Psychological Disorders
8 Hot and Cold Applications
B Infection Control Procedures (may be demonstrated in classroom lab andor patient care settings) 1 Asepsis 2 Techniques for strict contact respiratory
enteric tuberculosis drainage universal and immunosuppressed patient isolation
TO BE SIGNED BY THE RN DIRECTOR OR SUPERVISOR I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
Signature ___________________________________________ Print Name___________________________________ Nursing License ___________________Exp Date__________ Telephone Number (_____)_ ____________________ Address _____________________________________________ Todayrsquos Date ________________________________ CityState ___________________________ Zip Code_______
55A-12 (Rev 1007) 2 Date Evaluated ____________ Initials ______
55A-6 (1015) - CONTINUED ON REVERSE -
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS RECORD OF CONVICTION
TYPE OR PRINT (USE BLUE OR BLACK INK ONLY) IF MORE SPACE IS NEEDED TO COMPLETE ANY SECTION PLEASE ATTACH ADDITIONAL SHEETS 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APARTMENT NUMBER)
3 CITY STATE ZIP
4 BIRTHDATE (MMDDYYYY) 6 TELEPHONE NUMBERS
CELL (_______) ________________________________________
HOME (_______) ________________________________________
BUSINESS (_______) ________________________________________
5 SOCIAL SECURITY OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER
7 Pursuant to Business and Professions Code Section 480 (c) any false statements included in this application may result in license denial Please carefully read all information contained on the front and back of this form before signing I declare under penalty of perjury under the laws of the State of California that the information provided herein and attachments is true and correct Signature ____________________________________________________________ Date ____________________________________
8 Are you or have you previously been licensed or certified as a psychiatric technician practical vocational or registered nurse or any other healthcare professional in this or any other state territory or country
Yes No
A
State
License Type
License
Expiration Date
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
B Has your license or certification ever been suspended revoked placed on probation or disciplined If Yes you must explain the basis for the disciplinary action and submit a copy of the disciplinary order
Yes No
C Have you used any other names If Yes list all other names used _______________________________________________________________
Yes No
9 Have you ever been convicted of pled guilty to or pled nolo contendere to ANY offense in the United States or a foreign country If YES you must complete item 12 on the back of this form
This includes every citation infraction misdemeanor andor felony excluding traffic violations under $1000 which do not involve alcohol dangerous drugs or controlled substances Convictions that were adjudicated in the juvenile court or convictions under California Health and Safety Code Sections 11357(b) (c) (d) (e) or Section 11360(b) which are two years or older should NOT be reported Convictions that were later dismissed pursuant to section 12034 12034a or 120341 of the California Penal Code or equivalent non-California law MUST be disclosed If you have obtained a dismissal of your conviction(s) pursuant to Penal Code sections 12034 12034(a) or 120341 please submit a certified copy of the court order dismissing the conviction(s) with your application
Yes No
10 Exclusive of juvenile court adjudications and criminal charges dismissed under section 10003 of the California Penal Code or equivalent non-California laws or convictions two years or older under California Health and Safety Code Sections 11357(b) (c) (d) (e) or section 11360(b) have you had a conviction that was set aside or later expunged from the records of the court If YES you must complete item 12 on the back of this form
Yes No
11 Is any court action pending against you or are you currently awaiting judgment and sentencing following entry of a plea or jury verdict If YES you must complete item 12 on the back of this form
Yes No
Important note You will be permitted to take the licensing examination regardless of any criminal conviction history you disclose However a determination as to whether your license will be granted or denied will not be made until you have passed the examination and the board has received all required conviction documentation
12 If you answered yes to item 9 10 or 11 you must provide all of the information requested below for each offense Department of Motor Vehicles printouts are not accepted in lieu of completing this section If more space is needed to complete this section please attach additional sheets
If you have been convicted of a crime you must submit certified court documents police reports and a detailed explanation in your own words for each offense (Certified courtpolice documents are obtained directly from the courtpolice department with an original stamp of certification Do not send copies as they will not contain an original certification and will not meet the requirement for certified documents If the police report andor court documents are no longer available you must obtain a statement from the police department or court attesting to that fact) Additionally please submit documents regarding your rehabilitation efforts such as
Proof that you complied with the terms of your parole probation restitution or any other court imposed sanctions Evidence of expungement proceedings pursuant to penal code section 12034 12034(a) or 120341 Any other evidence of rehabilitation you wish the board to consider
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
Notice on Collection of Personal Information For Applicants and Licensees
Collection and Use of Personal Information The Board of Vocational Nursing and Psychiatric Technicians (BVNPT) of the Department of Consumer Affairs (DCA) collects the personal information requested on this form as authorized by Business and Professions Code Section 30 (General Provisions) Business and Professions Code Division 2 Chapter 65 Articles 1 amp 2 (Vocational Nursing Practice Act) and Chapter 10 Articles 1 amp 2 (Psychiatric Technicians Law) and California Code of Regulations Title 16 Division 25 Chapter 1 (Vocational Nurses) and Chapter 2 (Psychiatric Technicians) The BVNPT uses this information principally to identify and evaluate applicants for licensure issue and renew licenses and enforce licensing standards set by law and regulation
Mandatory Submission Submission of the requested information is mandatory The BVNPT cannot consider your application for licensure or renewal unless you provide all of the requested information
Access to Personal Information You may review the records maintained by the BVNPT that contain your personal information as permitted by the Information Practices Act See below for contact information
Possible Disclosure of Personal Information The BVNPT makes every effort to protect the personal information you provide The information you provide however may be disclosed in the following circumstances
In response to a Public Records Act request (Government Code Section 6250 and following) as allowed by the Information Practices Act (Civil Code Section 1798 and following)
To another government agency as required or permitted by state or federal law or
In response to a court or administrative order a subpoena or a search warrant
Contact Information For questions about this notice or access to your records you may contact the BVNPT at 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833 (916) 263-7800 or email bvnptdcacagov
55P-1 (42109)
7C Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From
THIS SPACE FOR OFFICE USE ONLY
__________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7E Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7F Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7G Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7H Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7I Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
7A Name of Hospital Registry or Health Agency Type of Duty General Private
Type of Patient Care for
Employment Period
From __________________________________________________ Name of RN Director or Supervisor
Medical
Surgical
Maternity
______________________ Month Day Year
To __________________________________________________ Your name while employed at this facility Pediatric
Other________________
______________________ Month Day Year
2
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROW N JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
In order to receive credit for nursing experience State law requires that the Board obtain verification of employment and certification from the Registered Nurse (RN) Director or Supervisor that the applicant has demonstrated the required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
INSTRUCTIONS TO APPLICANT
Complete Part I on the second page of this form and provide a copy of both pages to each employer for the past ten (10) years (You may reproduce as many copies of this form as needed)
This form must be completed in full by the RN Director or Supervisor and returned directly to you in the employerrsquos sealed business envelope The UNOPENED sealed envelopes containing the Employment Verification Forms must be submitted to the Board with your Application for Vocational Nurse Licensure
If you already have an application on the file with the Board and are submitting additional experience the employment verification form may be submitted to the Board by the applicant or the employer but must be received in the employerrsquos sealed business envelope
Please be advised that employment verification forms that appear to have been opened or altered will not be accepted The Board conducts random audits to verify the accuracy of the information submitted Discrepancies or false statements included in the application can result in licensure denial
INSTRUCTIONS TO EMPLOYER
The applicant on page two of this form is applying for licensure as a vocational nurse under Section 2873 of the Business and Professions Code In order for the applicant to receive credit for nursing experience State law requires the Board to obtain verification of employment and certification from the RN Director or Supervisor that the applicant has demonstrated required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
Please complete Parts II III and IV on page two of this form and return it to the applicant in a sealed business envelope Indicate on the outside of the envelope ldquoEmployment Verification Enclosed ndash Do Not Openrdquo It is the applicantrsquos responsibility to collect the Employment Verification Form(s) and submit them with the application for licensure
Part II Indicate the name and type of facility where the experience was obtained Part III Provide the specific dates that the applicant worked under your supervision in the area of
nursing being verified Additionally indicate if the applicant was employed full time (40 hrswk) or part time and include the number of hours worked in each area The Board MUST receive a breakdown of the number of hours spent in each area in order to evaluate the experience
Part IV Indicate whether the applicant has satisfactorily demonstrated each of the knowledge and skills with safety to the patient The skills listed in Part IV(B) may be demonstrated in classroom lab andor patient care settings
Thank you for your assistance Please feel free to contact the Board at (916) 263-7800 if you have any questions
55A-12 (Rev 1007) 1
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
Part I is to be completed by the applicant and submitted to employers for verification of nursing experience The remainder of this form must be completed by the RN Director or Supervisor and returned to the applicant by the employer in a sealed business envelope FORMS CONTAINING STRIKEOUTS OR CORRECTIONS WILL NOT BE ACCEPTED (See Page 1 for detailed instructions on how to complete this form)
Part I To be completed by the Applicant (print or type - do not use pencil)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 NAME WHILE EMPLOYED AT THIS FACILITY 5 SOCIAL SECURITY NUMBER
NOT required but may assist employer in locating records
6 DAYTIME TELEPHONE NUMBER
( )_________________________________ Area Code
Part II To be completed by the Employer - Indicate the name and type of facility where the experience was obtained
Name of facility where experience was obtained
Type of facility Acute or sub-acute(hospital) Home Health
Convalescent Skilled NursingLong Term Care Outpatient Clinicemergency care Other
Assisted Living
Part III To be completed by the Employer - Include dates and the area of nursing being verified Indicate if employment was full-time (40 hrswk) or part-time and include the total number of hours worked in each area
Areas of Bedside Nursing Experience Employment Period (MonthDateYear) Hours Worked
Per Week Total Hours In Each Area
For Office Use Only
Medical-Surgical Nursing From To Pediatric Nursing From To Maternity Nursing From To Genitourinary Nursing From To Psychiatric Nursing From To Office Nursing From To Long Term CareConvalescent From To Private Duty (in a general acute care facility) From To Other From To
Part IV To be completed by the Employer - Indicate if the applicant has satisfactorily demonstrated the following knowledge and skills with safety to the patient
Knowledge and Skills Demonstrated Knowledge and Skills Demonstrated YES NO YES NO
A Basic Bedside Nursing 1 Ambulation Techniques 9 Intake and Output 2 Bedmaking 10 Personal Hygiene and Comfort Measures 3 Urinary Catheter Care 11 Positioning and Transfer 4 Collection of Specimens 12 Range of Motion 5 Diabetic Testing 13 Skin Care 6 Administration of a Cleansing Enema 14 Vital Signs 7 Feeding Patient 15 Communication Skills Both Verbal and
Written Including Communication With Patients Who Have Psychological Disorders
8 Hot and Cold Applications
B Infection Control Procedures (may be demonstrated in classroom lab andor patient care settings) 1 Asepsis 2 Techniques for strict contact respiratory
enteric tuberculosis drainage universal and immunosuppressed patient isolation
TO BE SIGNED BY THE RN DIRECTOR OR SUPERVISOR I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
Signature ___________________________________________ Print Name___________________________________ Nursing License ___________________Exp Date__________ Telephone Number (_____)_ ____________________ Address _____________________________________________ Todayrsquos Date ________________________________ CityState ___________________________ Zip Code_______
55A-12 (Rev 1007) 2 Date Evaluated ____________ Initials ______
55A-6 (1015) - CONTINUED ON REVERSE -
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS RECORD OF CONVICTION
TYPE OR PRINT (USE BLUE OR BLACK INK ONLY) IF MORE SPACE IS NEEDED TO COMPLETE ANY SECTION PLEASE ATTACH ADDITIONAL SHEETS 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APARTMENT NUMBER)
3 CITY STATE ZIP
4 BIRTHDATE (MMDDYYYY) 6 TELEPHONE NUMBERS
CELL (_______) ________________________________________
HOME (_______) ________________________________________
BUSINESS (_______) ________________________________________
5 SOCIAL SECURITY OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER
7 Pursuant to Business and Professions Code Section 480 (c) any false statements included in this application may result in license denial Please carefully read all information contained on the front and back of this form before signing I declare under penalty of perjury under the laws of the State of California that the information provided herein and attachments is true and correct Signature ____________________________________________________________ Date ____________________________________
8 Are you or have you previously been licensed or certified as a psychiatric technician practical vocational or registered nurse or any other healthcare professional in this or any other state territory or country
Yes No
A
State
License Type
License
Expiration Date
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
B Has your license or certification ever been suspended revoked placed on probation or disciplined If Yes you must explain the basis for the disciplinary action and submit a copy of the disciplinary order
Yes No
C Have you used any other names If Yes list all other names used _______________________________________________________________
Yes No
9 Have you ever been convicted of pled guilty to or pled nolo contendere to ANY offense in the United States or a foreign country If YES you must complete item 12 on the back of this form
This includes every citation infraction misdemeanor andor felony excluding traffic violations under $1000 which do not involve alcohol dangerous drugs or controlled substances Convictions that were adjudicated in the juvenile court or convictions under California Health and Safety Code Sections 11357(b) (c) (d) (e) or Section 11360(b) which are two years or older should NOT be reported Convictions that were later dismissed pursuant to section 12034 12034a or 120341 of the California Penal Code or equivalent non-California law MUST be disclosed If you have obtained a dismissal of your conviction(s) pursuant to Penal Code sections 12034 12034(a) or 120341 please submit a certified copy of the court order dismissing the conviction(s) with your application
Yes No
10 Exclusive of juvenile court adjudications and criminal charges dismissed under section 10003 of the California Penal Code or equivalent non-California laws or convictions two years or older under California Health and Safety Code Sections 11357(b) (c) (d) (e) or section 11360(b) have you had a conviction that was set aside or later expunged from the records of the court If YES you must complete item 12 on the back of this form
Yes No
11 Is any court action pending against you or are you currently awaiting judgment and sentencing following entry of a plea or jury verdict If YES you must complete item 12 on the back of this form
Yes No
Important note You will be permitted to take the licensing examination regardless of any criminal conviction history you disclose However a determination as to whether your license will be granted or denied will not be made until you have passed the examination and the board has received all required conviction documentation
12 If you answered yes to item 9 10 or 11 you must provide all of the information requested below for each offense Department of Motor Vehicles printouts are not accepted in lieu of completing this section If more space is needed to complete this section please attach additional sheets
If you have been convicted of a crime you must submit certified court documents police reports and a detailed explanation in your own words for each offense (Certified courtpolice documents are obtained directly from the courtpolice department with an original stamp of certification Do not send copies as they will not contain an original certification and will not meet the requirement for certified documents If the police report andor court documents are no longer available you must obtain a statement from the police department or court attesting to that fact) Additionally please submit documents regarding your rehabilitation efforts such as
Proof that you complied with the terms of your parole probation restitution or any other court imposed sanctions Evidence of expungement proceedings pursuant to penal code section 12034 12034(a) or 120341 Any other evidence of rehabilitation you wish the board to consider
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
Notice on Collection of Personal Information For Applicants and Licensees
Collection and Use of Personal Information The Board of Vocational Nursing and Psychiatric Technicians (BVNPT) of the Department of Consumer Affairs (DCA) collects the personal information requested on this form as authorized by Business and Professions Code Section 30 (General Provisions) Business and Professions Code Division 2 Chapter 65 Articles 1 amp 2 (Vocational Nursing Practice Act) and Chapter 10 Articles 1 amp 2 (Psychiatric Technicians Law) and California Code of Regulations Title 16 Division 25 Chapter 1 (Vocational Nurses) and Chapter 2 (Psychiatric Technicians) The BVNPT uses this information principally to identify and evaluate applicants for licensure issue and renew licenses and enforce licensing standards set by law and regulation
Mandatory Submission Submission of the requested information is mandatory The BVNPT cannot consider your application for licensure or renewal unless you provide all of the requested information
Access to Personal Information You may review the records maintained by the BVNPT that contain your personal information as permitted by the Information Practices Act See below for contact information
Possible Disclosure of Personal Information The BVNPT makes every effort to protect the personal information you provide The information you provide however may be disclosed in the following circumstances
In response to a Public Records Act request (Government Code Section 6250 and following) as allowed by the Information Practices Act (Civil Code Section 1798 and following)
To another government agency as required or permitted by state or federal law or
In response to a court or administrative order a subpoena or a search warrant
Contact Information For questions about this notice or access to your records you may contact the BVNPT at 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833 (916) 263-7800 or email bvnptdcacagov
55P-1 (42109)
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROW N JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
In order to receive credit for nursing experience State law requires that the Board obtain verification of employment and certification from the Registered Nurse (RN) Director or Supervisor that the applicant has demonstrated the required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
INSTRUCTIONS TO APPLICANT
Complete Part I on the second page of this form and provide a copy of both pages to each employer for the past ten (10) years (You may reproduce as many copies of this form as needed)
This form must be completed in full by the RN Director or Supervisor and returned directly to you in the employerrsquos sealed business envelope The UNOPENED sealed envelopes containing the Employment Verification Forms must be submitted to the Board with your Application for Vocational Nurse Licensure
If you already have an application on the file with the Board and are submitting additional experience the employment verification form may be submitted to the Board by the applicant or the employer but must be received in the employerrsquos sealed business envelope
Please be advised that employment verification forms that appear to have been opened or altered will not be accepted The Board conducts random audits to verify the accuracy of the information submitted Discrepancies or false statements included in the application can result in licensure denial
INSTRUCTIONS TO EMPLOYER
The applicant on page two of this form is applying for licensure as a vocational nurse under Section 2873 of the Business and Professions Code In order for the applicant to receive credit for nursing experience State law requires the Board to obtain verification of employment and certification from the RN Director or Supervisor that the applicant has demonstrated required knowledge and skills during the applicantrsquos paid general duty inpatient bedside nursing experience
Please complete Parts II III and IV on page two of this form and return it to the applicant in a sealed business envelope Indicate on the outside of the envelope ldquoEmployment Verification Enclosed ndash Do Not Openrdquo It is the applicantrsquos responsibility to collect the Employment Verification Form(s) and submit them with the application for licensure
Part II Indicate the name and type of facility where the experience was obtained Part III Provide the specific dates that the applicant worked under your supervision in the area of
nursing being verified Additionally indicate if the applicant was employed full time (40 hrswk) or part time and include the number of hours worked in each area The Board MUST receive a breakdown of the number of hours spent in each area in order to evaluate the experience
Part IV Indicate whether the applicant has satisfactorily demonstrated each of the knowledge and skills with safety to the patient The skills listed in Part IV(B) may be demonstrated in classroom lab andor patient care settings
Thank you for your assistance Please feel free to contact the Board at (916) 263-7800 if you have any questions
55A-12 (Rev 1007) 1
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
Part I is to be completed by the applicant and submitted to employers for verification of nursing experience The remainder of this form must be completed by the RN Director or Supervisor and returned to the applicant by the employer in a sealed business envelope FORMS CONTAINING STRIKEOUTS OR CORRECTIONS WILL NOT BE ACCEPTED (See Page 1 for detailed instructions on how to complete this form)
Part I To be completed by the Applicant (print or type - do not use pencil)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 NAME WHILE EMPLOYED AT THIS FACILITY 5 SOCIAL SECURITY NUMBER
NOT required but may assist employer in locating records
6 DAYTIME TELEPHONE NUMBER
( )_________________________________ Area Code
Part II To be completed by the Employer - Indicate the name and type of facility where the experience was obtained
Name of facility where experience was obtained
Type of facility Acute or sub-acute(hospital) Home Health
Convalescent Skilled NursingLong Term Care Outpatient Clinicemergency care Other
Assisted Living
Part III To be completed by the Employer - Include dates and the area of nursing being verified Indicate if employment was full-time (40 hrswk) or part-time and include the total number of hours worked in each area
Areas of Bedside Nursing Experience Employment Period (MonthDateYear) Hours Worked
Per Week Total Hours In Each Area
For Office Use Only
Medical-Surgical Nursing From To Pediatric Nursing From To Maternity Nursing From To Genitourinary Nursing From To Psychiatric Nursing From To Office Nursing From To Long Term CareConvalescent From To Private Duty (in a general acute care facility) From To Other From To
Part IV To be completed by the Employer - Indicate if the applicant has satisfactorily demonstrated the following knowledge and skills with safety to the patient
Knowledge and Skills Demonstrated Knowledge and Skills Demonstrated YES NO YES NO
A Basic Bedside Nursing 1 Ambulation Techniques 9 Intake and Output 2 Bedmaking 10 Personal Hygiene and Comfort Measures 3 Urinary Catheter Care 11 Positioning and Transfer 4 Collection of Specimens 12 Range of Motion 5 Diabetic Testing 13 Skin Care 6 Administration of a Cleansing Enema 14 Vital Signs 7 Feeding Patient 15 Communication Skills Both Verbal and
Written Including Communication With Patients Who Have Psychological Disorders
8 Hot and Cold Applications
B Infection Control Procedures (may be demonstrated in classroom lab andor patient care settings) 1 Asepsis 2 Techniques for strict contact respiratory
enteric tuberculosis drainage universal and immunosuppressed patient isolation
TO BE SIGNED BY THE RN DIRECTOR OR SUPERVISOR I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
Signature ___________________________________________ Print Name___________________________________ Nursing License ___________________Exp Date__________ Telephone Number (_____)_ ____________________ Address _____________________________________________ Todayrsquos Date ________________________________ CityState ___________________________ Zip Code_______
55A-12 (Rev 1007) 2 Date Evaluated ____________ Initials ______
55A-6 (1015) - CONTINUED ON REVERSE -
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS RECORD OF CONVICTION
TYPE OR PRINT (USE BLUE OR BLACK INK ONLY) IF MORE SPACE IS NEEDED TO COMPLETE ANY SECTION PLEASE ATTACH ADDITIONAL SHEETS 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APARTMENT NUMBER)
3 CITY STATE ZIP
4 BIRTHDATE (MMDDYYYY) 6 TELEPHONE NUMBERS
CELL (_______) ________________________________________
HOME (_______) ________________________________________
BUSINESS (_______) ________________________________________
5 SOCIAL SECURITY OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER
7 Pursuant to Business and Professions Code Section 480 (c) any false statements included in this application may result in license denial Please carefully read all information contained on the front and back of this form before signing I declare under penalty of perjury under the laws of the State of California that the information provided herein and attachments is true and correct Signature ____________________________________________________________ Date ____________________________________
8 Are you or have you previously been licensed or certified as a psychiatric technician practical vocational or registered nurse or any other healthcare professional in this or any other state territory or country
Yes No
A
State
License Type
License
Expiration Date
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
B Has your license or certification ever been suspended revoked placed on probation or disciplined If Yes you must explain the basis for the disciplinary action and submit a copy of the disciplinary order
Yes No
C Have you used any other names If Yes list all other names used _______________________________________________________________
Yes No
9 Have you ever been convicted of pled guilty to or pled nolo contendere to ANY offense in the United States or a foreign country If YES you must complete item 12 on the back of this form
This includes every citation infraction misdemeanor andor felony excluding traffic violations under $1000 which do not involve alcohol dangerous drugs or controlled substances Convictions that were adjudicated in the juvenile court or convictions under California Health and Safety Code Sections 11357(b) (c) (d) (e) or Section 11360(b) which are two years or older should NOT be reported Convictions that were later dismissed pursuant to section 12034 12034a or 120341 of the California Penal Code or equivalent non-California law MUST be disclosed If you have obtained a dismissal of your conviction(s) pursuant to Penal Code sections 12034 12034(a) or 120341 please submit a certified copy of the court order dismissing the conviction(s) with your application
Yes No
10 Exclusive of juvenile court adjudications and criminal charges dismissed under section 10003 of the California Penal Code or equivalent non-California laws or convictions two years or older under California Health and Safety Code Sections 11357(b) (c) (d) (e) or section 11360(b) have you had a conviction that was set aside or later expunged from the records of the court If YES you must complete item 12 on the back of this form
Yes No
11 Is any court action pending against you or are you currently awaiting judgment and sentencing following entry of a plea or jury verdict If YES you must complete item 12 on the back of this form
Yes No
Important note You will be permitted to take the licensing examination regardless of any criminal conviction history you disclose However a determination as to whether your license will be granted or denied will not be made until you have passed the examination and the board has received all required conviction documentation
12 If you answered yes to item 9 10 or 11 you must provide all of the information requested below for each offense Department of Motor Vehicles printouts are not accepted in lieu of completing this section If more space is needed to complete this section please attach additional sheets
If you have been convicted of a crime you must submit certified court documents police reports and a detailed explanation in your own words for each offense (Certified courtpolice documents are obtained directly from the courtpolice department with an original stamp of certification Do not send copies as they will not contain an original certification and will not meet the requirement for certified documents If the police report andor court documents are no longer available you must obtain a statement from the police department or court attesting to that fact) Additionally please submit documents regarding your rehabilitation efforts such as
Proof that you complied with the terms of your parole probation restitution or any other court imposed sanctions Evidence of expungement proceedings pursuant to penal code section 12034 12034(a) or 120341 Any other evidence of rehabilitation you wish the board to consider
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
Notice on Collection of Personal Information For Applicants and Licensees
Collection and Use of Personal Information The Board of Vocational Nursing and Psychiatric Technicians (BVNPT) of the Department of Consumer Affairs (DCA) collects the personal information requested on this form as authorized by Business and Professions Code Section 30 (General Provisions) Business and Professions Code Division 2 Chapter 65 Articles 1 amp 2 (Vocational Nursing Practice Act) and Chapter 10 Articles 1 amp 2 (Psychiatric Technicians Law) and California Code of Regulations Title 16 Division 25 Chapter 1 (Vocational Nurses) and Chapter 2 (Psychiatric Technicians) The BVNPT uses this information principally to identify and evaluate applicants for licensure issue and renew licenses and enforce licensing standards set by law and regulation
Mandatory Submission Submission of the requested information is mandatory The BVNPT cannot consider your application for licensure or renewal unless you provide all of the requested information
Access to Personal Information You may review the records maintained by the BVNPT that contain your personal information as permitted by the Information Practices Act See below for contact information
Possible Disclosure of Personal Information The BVNPT makes every effort to protect the personal information you provide The information you provide however may be disclosed in the following circumstances
In response to a Public Records Act request (Government Code Section 6250 and following) as allowed by the Information Practices Act (Civil Code Section 1798 and following)
To another government agency as required or permitted by state or federal law or
In response to a court or administrative order a subpoena or a search warrant
Contact Information For questions about this notice or access to your records you may contact the BVNPT at 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833 (916) 263-7800 or email bvnptdcacagov
55P-1 (42109)
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS EMPLOYMENT VERIFICATION ndash NURSING EXPERIENCE
Part I is to be completed by the applicant and submitted to employers for verification of nursing experience The remainder of this form must be completed by the RN Director or Supervisor and returned to the applicant by the employer in a sealed business envelope FORMS CONTAINING STRIKEOUTS OR CORRECTIONS WILL NOT BE ACCEPTED (See Page 1 for detailed instructions on how to complete this form)
Part I To be completed by the Applicant (print or type - do not use pencil)
1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APT NO)
3 CITY STATE ZIP
4 NAME WHILE EMPLOYED AT THIS FACILITY 5 SOCIAL SECURITY NUMBER
NOT required but may assist employer in locating records
6 DAYTIME TELEPHONE NUMBER
( )_________________________________ Area Code
Part II To be completed by the Employer - Indicate the name and type of facility where the experience was obtained
Name of facility where experience was obtained
Type of facility Acute or sub-acute(hospital) Home Health
Convalescent Skilled NursingLong Term Care Outpatient Clinicemergency care Other
Assisted Living
Part III To be completed by the Employer - Include dates and the area of nursing being verified Indicate if employment was full-time (40 hrswk) or part-time and include the total number of hours worked in each area
Areas of Bedside Nursing Experience Employment Period (MonthDateYear) Hours Worked
Per Week Total Hours In Each Area
For Office Use Only
Medical-Surgical Nursing From To Pediatric Nursing From To Maternity Nursing From To Genitourinary Nursing From To Psychiatric Nursing From To Office Nursing From To Long Term CareConvalescent From To Private Duty (in a general acute care facility) From To Other From To
Part IV To be completed by the Employer - Indicate if the applicant has satisfactorily demonstrated the following knowledge and skills with safety to the patient
Knowledge and Skills Demonstrated Knowledge and Skills Demonstrated YES NO YES NO
A Basic Bedside Nursing 1 Ambulation Techniques 9 Intake and Output 2 Bedmaking 10 Personal Hygiene and Comfort Measures 3 Urinary Catheter Care 11 Positioning and Transfer 4 Collection of Specimens 12 Range of Motion 5 Diabetic Testing 13 Skin Care 6 Administration of a Cleansing Enema 14 Vital Signs 7 Feeding Patient 15 Communication Skills Both Verbal and
Written Including Communication With Patients Who Have Psychological Disorders
8 Hot and Cold Applications
B Infection Control Procedures (may be demonstrated in classroom lab andor patient care settings) 1 Asepsis 2 Techniques for strict contact respiratory
enteric tuberculosis drainage universal and immunosuppressed patient isolation
TO BE SIGNED BY THE RN DIRECTOR OR SUPERVISOR I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT
Signature ___________________________________________ Print Name___________________________________ Nursing License ___________________Exp Date__________ Telephone Number (_____)_ ____________________ Address _____________________________________________ Todayrsquos Date ________________________________ CityState ___________________________ Zip Code_______
55A-12 (Rev 1007) 2 Date Evaluated ____________ Initials ______
55A-6 (1015) - CONTINUED ON REVERSE -
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS RECORD OF CONVICTION
TYPE OR PRINT (USE BLUE OR BLACK INK ONLY) IF MORE SPACE IS NEEDED TO COMPLETE ANY SECTION PLEASE ATTACH ADDITIONAL SHEETS 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APARTMENT NUMBER)
3 CITY STATE ZIP
4 BIRTHDATE (MMDDYYYY) 6 TELEPHONE NUMBERS
CELL (_______) ________________________________________
HOME (_______) ________________________________________
BUSINESS (_______) ________________________________________
5 SOCIAL SECURITY OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER
7 Pursuant to Business and Professions Code Section 480 (c) any false statements included in this application may result in license denial Please carefully read all information contained on the front and back of this form before signing I declare under penalty of perjury under the laws of the State of California that the information provided herein and attachments is true and correct Signature ____________________________________________________________ Date ____________________________________
8 Are you or have you previously been licensed or certified as a psychiatric technician practical vocational or registered nurse or any other healthcare professional in this or any other state territory or country
Yes No
A
State
License Type
License
Expiration Date
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
B Has your license or certification ever been suspended revoked placed on probation or disciplined If Yes you must explain the basis for the disciplinary action and submit a copy of the disciplinary order
Yes No
C Have you used any other names If Yes list all other names used _______________________________________________________________
Yes No
9 Have you ever been convicted of pled guilty to or pled nolo contendere to ANY offense in the United States or a foreign country If YES you must complete item 12 on the back of this form
This includes every citation infraction misdemeanor andor felony excluding traffic violations under $1000 which do not involve alcohol dangerous drugs or controlled substances Convictions that were adjudicated in the juvenile court or convictions under California Health and Safety Code Sections 11357(b) (c) (d) (e) or Section 11360(b) which are two years or older should NOT be reported Convictions that were later dismissed pursuant to section 12034 12034a or 120341 of the California Penal Code or equivalent non-California law MUST be disclosed If you have obtained a dismissal of your conviction(s) pursuant to Penal Code sections 12034 12034(a) or 120341 please submit a certified copy of the court order dismissing the conviction(s) with your application
Yes No
10 Exclusive of juvenile court adjudications and criminal charges dismissed under section 10003 of the California Penal Code or equivalent non-California laws or convictions two years or older under California Health and Safety Code Sections 11357(b) (c) (d) (e) or section 11360(b) have you had a conviction that was set aside or later expunged from the records of the court If YES you must complete item 12 on the back of this form
Yes No
11 Is any court action pending against you or are you currently awaiting judgment and sentencing following entry of a plea or jury verdict If YES you must complete item 12 on the back of this form
Yes No
Important note You will be permitted to take the licensing examination regardless of any criminal conviction history you disclose However a determination as to whether your license will be granted or denied will not be made until you have passed the examination and the board has received all required conviction documentation
12 If you answered yes to item 9 10 or 11 you must provide all of the information requested below for each offense Department of Motor Vehicles printouts are not accepted in lieu of completing this section If more space is needed to complete this section please attach additional sheets
If you have been convicted of a crime you must submit certified court documents police reports and a detailed explanation in your own words for each offense (Certified courtpolice documents are obtained directly from the courtpolice department with an original stamp of certification Do not send copies as they will not contain an original certification and will not meet the requirement for certified documents If the police report andor court documents are no longer available you must obtain a statement from the police department or court attesting to that fact) Additionally please submit documents regarding your rehabilitation efforts such as
Proof that you complied with the terms of your parole probation restitution or any other court imposed sanctions Evidence of expungement proceedings pursuant to penal code section 12034 12034(a) or 120341 Any other evidence of rehabilitation you wish the board to consider
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
Notice on Collection of Personal Information For Applicants and Licensees
Collection and Use of Personal Information The Board of Vocational Nursing and Psychiatric Technicians (BVNPT) of the Department of Consumer Affairs (DCA) collects the personal information requested on this form as authorized by Business and Professions Code Section 30 (General Provisions) Business and Professions Code Division 2 Chapter 65 Articles 1 amp 2 (Vocational Nursing Practice Act) and Chapter 10 Articles 1 amp 2 (Psychiatric Technicians Law) and California Code of Regulations Title 16 Division 25 Chapter 1 (Vocational Nurses) and Chapter 2 (Psychiatric Technicians) The BVNPT uses this information principally to identify and evaluate applicants for licensure issue and renew licenses and enforce licensing standards set by law and regulation
Mandatory Submission Submission of the requested information is mandatory The BVNPT cannot consider your application for licensure or renewal unless you provide all of the requested information
Access to Personal Information You may review the records maintained by the BVNPT that contain your personal information as permitted by the Information Practices Act See below for contact information
Possible Disclosure of Personal Information The BVNPT makes every effort to protect the personal information you provide The information you provide however may be disclosed in the following circumstances
In response to a Public Records Act request (Government Code Section 6250 and following) as allowed by the Information Practices Act (Civil Code Section 1798 and following)
To another government agency as required or permitted by state or federal law or
In response to a court or administrative order a subpoena or a search warrant
Contact Information For questions about this notice or access to your records you may contact the BVNPT at 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833 (916) 263-7800 or email bvnptdcacagov
55P-1 (42109)
55A-6 (1015) - CONTINUED ON REVERSE -
BOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS RECORD OF CONVICTION
TYPE OR PRINT (USE BLUE OR BLACK INK ONLY) IF MORE SPACE IS NEEDED TO COMPLETE ANY SECTION PLEASE ATTACH ADDITIONAL SHEETS 1 NAME (LAST) (FIRST) (MIDDLE)
2 ADDRESS (STREET OR BOX NUMBER) (APARTMENT NUMBER)
3 CITY STATE ZIP
4 BIRTHDATE (MMDDYYYY) 6 TELEPHONE NUMBERS
CELL (_______) ________________________________________
HOME (_______) ________________________________________
BUSINESS (_______) ________________________________________
5 SOCIAL SECURITY OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER
7 Pursuant to Business and Professions Code Section 480 (c) any false statements included in this application may result in license denial Please carefully read all information contained on the front and back of this form before signing I declare under penalty of perjury under the laws of the State of California that the information provided herein and attachments is true and correct Signature ____________________________________________________________ Date ____________________________________
8 Are you or have you previously been licensed or certified as a psychiatric technician practical vocational or registered nurse or any other healthcare professional in this or any other state territory or country
Yes No
A
State
License Type
License
Expiration Date
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
PT LVNLPN RN Other (specify) _____________
B Has your license or certification ever been suspended revoked placed on probation or disciplined If Yes you must explain the basis for the disciplinary action and submit a copy of the disciplinary order
Yes No
C Have you used any other names If Yes list all other names used _______________________________________________________________
Yes No
9 Have you ever been convicted of pled guilty to or pled nolo contendere to ANY offense in the United States or a foreign country If YES you must complete item 12 on the back of this form
This includes every citation infraction misdemeanor andor felony excluding traffic violations under $1000 which do not involve alcohol dangerous drugs or controlled substances Convictions that were adjudicated in the juvenile court or convictions under California Health and Safety Code Sections 11357(b) (c) (d) (e) or Section 11360(b) which are two years or older should NOT be reported Convictions that were later dismissed pursuant to section 12034 12034a or 120341 of the California Penal Code or equivalent non-California law MUST be disclosed If you have obtained a dismissal of your conviction(s) pursuant to Penal Code sections 12034 12034(a) or 120341 please submit a certified copy of the court order dismissing the conviction(s) with your application
Yes No
10 Exclusive of juvenile court adjudications and criminal charges dismissed under section 10003 of the California Penal Code or equivalent non-California laws or convictions two years or older under California Health and Safety Code Sections 11357(b) (c) (d) (e) or section 11360(b) have you had a conviction that was set aside or later expunged from the records of the court If YES you must complete item 12 on the back of this form
Yes No
11 Is any court action pending against you or are you currently awaiting judgment and sentencing following entry of a plea or jury verdict If YES you must complete item 12 on the back of this form
Yes No
Important note You will be permitted to take the licensing examination regardless of any criminal conviction history you disclose However a determination as to whether your license will be granted or denied will not be made until you have passed the examination and the board has received all required conviction documentation
12 If you answered yes to item 9 10 or 11 you must provide all of the information requested below for each offense Department of Motor Vehicles printouts are not accepted in lieu of completing this section If more space is needed to complete this section please attach additional sheets
If you have been convicted of a crime you must submit certified court documents police reports and a detailed explanation in your own words for each offense (Certified courtpolice documents are obtained directly from the courtpolice department with an original stamp of certification Do not send copies as they will not contain an original certification and will not meet the requirement for certified documents If the police report andor court documents are no longer available you must obtain a statement from the police department or court attesting to that fact) Additionally please submit documents regarding your rehabilitation efforts such as
Proof that you complied with the terms of your parole probation restitution or any other court imposed sanctions Evidence of expungement proceedings pursuant to penal code section 12034 12034(a) or 120341 Any other evidence of rehabilitation you wish the board to consider
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
Notice on Collection of Personal Information For Applicants and Licensees
Collection and Use of Personal Information The Board of Vocational Nursing and Psychiatric Technicians (BVNPT) of the Department of Consumer Affairs (DCA) collects the personal information requested on this form as authorized by Business and Professions Code Section 30 (General Provisions) Business and Professions Code Division 2 Chapter 65 Articles 1 amp 2 (Vocational Nursing Practice Act) and Chapter 10 Articles 1 amp 2 (Psychiatric Technicians Law) and California Code of Regulations Title 16 Division 25 Chapter 1 (Vocational Nurses) and Chapter 2 (Psychiatric Technicians) The BVNPT uses this information principally to identify and evaluate applicants for licensure issue and renew licenses and enforce licensing standards set by law and regulation
Mandatory Submission Submission of the requested information is mandatory The BVNPT cannot consider your application for licensure or renewal unless you provide all of the requested information
Access to Personal Information You may review the records maintained by the BVNPT that contain your personal information as permitted by the Information Practices Act See below for contact information
Possible Disclosure of Personal Information The BVNPT makes every effort to protect the personal information you provide The information you provide however may be disclosed in the following circumstances
In response to a Public Records Act request (Government Code Section 6250 and following) as allowed by the Information Practices Act (Civil Code Section 1798 and following)
To another government agency as required or permitted by state or federal law or
In response to a court or administrative order a subpoena or a search warrant
Contact Information For questions about this notice or access to your records you may contact the BVNPT at 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833 (916) 263-7800 or email bvnptdcacagov
55P-1 (42109)
Important note You will be permitted to take the licensing examination regardless of any criminal conviction history you disclose However a determination as to whether your license will be granted or denied will not be made until you have passed the examination and the board has received all required conviction documentation
12 If you answered yes to item 9 10 or 11 you must provide all of the information requested below for each offense Department of Motor Vehicles printouts are not accepted in lieu of completing this section If more space is needed to complete this section please attach additional sheets
If you have been convicted of a crime you must submit certified court documents police reports and a detailed explanation in your own words for each offense (Certified courtpolice documents are obtained directly from the courtpolice department with an original stamp of certification Do not send copies as they will not contain an original certification and will not meet the requirement for certified documents If the police report andor court documents are no longer available you must obtain a statement from the police department or court attesting to that fact) Additionally please submit documents regarding your rehabilitation efforts such as
Proof that you complied with the terms of your parole probation restitution or any other court imposed sanctions Evidence of expungement proceedings pursuant to penal code section 12034 12034(a) or 120341 Any other evidence of rehabilitation you wish the board to consider
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________
A Date of Offense ________________________ B City and State of Offense ______________________________________________________________________________________
C Name and location of court where your case was heard _______________________________________________________________________________________________________
D Details of the offense of which you were convicted ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
E Date of Conviction ____________________________ F Date(s) of Imprisonment if applicable ______________________________________________________________________
G Amount of fine paid ____________________________ H Period of Probation ______________________________________________________________________________________
I Conditions of Probation ______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
Notice on Collection of Personal Information For Applicants and Licensees
Collection and Use of Personal Information The Board of Vocational Nursing and Psychiatric Technicians (BVNPT) of the Department of Consumer Affairs (DCA) collects the personal information requested on this form as authorized by Business and Professions Code Section 30 (General Provisions) Business and Professions Code Division 2 Chapter 65 Articles 1 amp 2 (Vocational Nursing Practice Act) and Chapter 10 Articles 1 amp 2 (Psychiatric Technicians Law) and California Code of Regulations Title 16 Division 25 Chapter 1 (Vocational Nurses) and Chapter 2 (Psychiatric Technicians) The BVNPT uses this information principally to identify and evaluate applicants for licensure issue and renew licenses and enforce licensing standards set by law and regulation
Mandatory Submission Submission of the requested information is mandatory The BVNPT cannot consider your application for licensure or renewal unless you provide all of the requested information
Access to Personal Information You may review the records maintained by the BVNPT that contain your personal information as permitted by the Information Practices Act See below for contact information
Possible Disclosure of Personal Information The BVNPT makes every effort to protect the personal information you provide The information you provide however may be disclosed in the following circumstances
In response to a Public Records Act request (Government Code Section 6250 and following) as allowed by the Information Practices Act (Civil Code Section 1798 and following)
To another government agency as required or permitted by state or federal law or
In response to a court or administrative order a subpoena or a search warrant
Contact Information For questions about this notice or access to your records you may contact the BVNPT at 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833 (916) 263-7800 or email bvnptdcacagov
55P-1 (42109)
BUSINESS CONSUMER SERVICES AND HOUSING AGENCY bull GOVERNOR EDMUND G BROWN JR
Board of Vocational Nursing and Psychiatric Technicians 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833-2945 Phone 916-263-7800 Fax 916-263-7855 wwwbvnptcagov
Notice on Collection of Personal Information For Applicants and Licensees
Collection and Use of Personal Information The Board of Vocational Nursing and Psychiatric Technicians (BVNPT) of the Department of Consumer Affairs (DCA) collects the personal information requested on this form as authorized by Business and Professions Code Section 30 (General Provisions) Business and Professions Code Division 2 Chapter 65 Articles 1 amp 2 (Vocational Nursing Practice Act) and Chapter 10 Articles 1 amp 2 (Psychiatric Technicians Law) and California Code of Regulations Title 16 Division 25 Chapter 1 (Vocational Nurses) and Chapter 2 (Psychiatric Technicians) The BVNPT uses this information principally to identify and evaluate applicants for licensure issue and renew licenses and enforce licensing standards set by law and regulation
Mandatory Submission Submission of the requested information is mandatory The BVNPT cannot consider your application for licensure or renewal unless you provide all of the requested information
Access to Personal Information You may review the records maintained by the BVNPT that contain your personal information as permitted by the Information Practices Act See below for contact information
Possible Disclosure of Personal Information The BVNPT makes every effort to protect the personal information you provide The information you provide however may be disclosed in the following circumstances
In response to a Public Records Act request (Government Code Section 6250 and following) as allowed by the Information Practices Act (Civil Code Section 1798 and following)
To another government agency as required or permitted by state or federal law or
In response to a court or administrative order a subpoena or a search warrant
Contact Information For questions about this notice or access to your records you may contact the BVNPT at 2535 Capitol Oaks Drive Suite 205 Sacramento CA 95833 (916) 263-7800 or email bvnptdcacagov
55P-1 (42109)